RHIT prep test 4

What is the key piece of data needed to link a patient's information who is seen in a variety of care settings?

When data has been lost in an EHR, which action is taken to remedy this problem?

What committee usually oversees the development and approval of new forms for the health record?

Provides a chronological summary of the patient's medical history and illness

Where would this note be "Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet."

In which department or unit is the health record number typically assigned?

Which of the following is not an individual user of the health record?

In a cancer registry, the accession number:

In an acute-care record: HEENT and CHEST documentation is located in the ____ of the record?

What makes the indexing of scanned health record more efficient because it can enter metadata automatically?

When meeting with the HIM professional during an on-site review, the surveyor would be looking for what type of informa?

Hw should hospital respond when patient requests copies of MR in electronic format when the hospital doesnt maintain DRS

Ensuring data are not altered during transmission across a network or during storage is called:

Which of the following systems is the key to identifying a patient's multiple hospitalizations?

What index contains a list maintained procedure code number for discharges from a facility during a specific time?

In long-term care, the resident's care plan is based on data collected in the:

Which of the following statements is true regarding HIPAA security?

Detailed treatment action steps is what kind of specialized progress note?

Progress note in patient's record 24hr after he visited patient. Which quality element is missing from progress note?

Which Joint Commission survey methodology involves evaluation that follows hospital experiences of past/current patients

Which of the following is the best definition of a forward map in data mapping?

What data quality is lacking if two HIM pros r abstracting the same data and when checked discrepancies are found?

What department should the MPI manager work with to correct procedural problems of admitting patients to the MPI?

Data set to organize data about public health issues to inform buyer and consumers about performance healthcare plan is:

What is the primary benefit of point-of-care charting?

Which data sets would be most useful in developing a matrix for identification of components of the legal health?

A record that fails quantitative analysis is missing the quality criterion of:

Which of the following are data that have been filtered and put into context?

The statement, "the unique patient identifier must be numeric," is an example of which of the following business rule ca

Which of the following is not true of good electronic forms design?

The right of an individual to keep personal health information from being disclosed to anyone is a definition of:

A secondary purpose of the health record is to provide support for which of the following?

Which of the following definitions best describes the concept of confidentiality?

Which of the following best describes data comprehensiveness?

General documentation guidelines apply to:

Crucial early step in designing an EHR is to develop a ___ in which the characteristics of each data element are defined

What file resource should be used when designing a data collection to collect data on patients in an acute-care hospital

Patient uploads fitness info and past medical history in their record. What type of system are they using?

Which of the following is necessary to ensure that each term is used in an EHR has a common meaning to all users?

Which of the following is the healthcare industry's leading standards-setting body in the country?

OASIS-C data are used to assess the ______ of home health services.

An RAI/MDS and care plan are found in records of patients in what setting?

Which of the following represents an example of data granularity?

Data sets serve two purposes. First is to identify data elements to be collected about each patient. The second is to:

The attending physician is responsible for which of the following types of acute-care documentation?

Which individuals serve as a bridge between IT and business and clinical areas while managing each key area?

What term describes processing of scanning past health records into the information system so there is an existing data

Which of the following is not a characteristic of high-quality healthcare data?

Health system show that diagnostic codes are not being reported to the correct level of detail, this is a problem w data

Wht should supervisor do if an audit trail shows an employee printing out far more records than the average user?

Which of the following is not a true statement about a hybrid health record system?

Notation for HTN patient: "Blood pressure adequately controlled." which part of problem-orientation HR progress note be?

which is the accrediting org since 1950s &determine if they are monitoring the quality of care provided?

This private, not-for-profit organization is committed to developing outcomes of behavior health and med rehabilitation

Which of the following materials is not documented in an emergency medical care record?

A patient's birth date and gender documented in the health record are examples of a data _____.

accrediting org instituted continuous improvement &sentinel event monitoring & uses tracer methodology during surveys

Which of the following statements best describes the difference between a hospital inpatient and a hospital outpatient?

When no H&P on the record at seven hours past this patient's admission time. This review process would be an example of:

When a user keys in 10101963, the computer displays it as 10/10/1963. What enables this?

An example or an __ is a physician reviewing lab results and the EHR screen displays results in red w flashing asterisk:

What quality of data is missing if admitting data says DOB is 3/21/1948 and dischargedats is 7/21/1948

Which of the following represents documentation of the patient's current and past health status?

The home health prospective payment system uses the _____ data set for patient assessments.

Access to HRs based on protected health information w in healthcare facility should be limited to employees who have a:

Which of following provides a standardized vocabulary for facilitating development of computer-based patient records?

Why should the copy and paste function not be used in the electronic health record?

Security safeguards must be developed for both paper and electronic processes. The meaning of this origin is called:

Which of the following is a primary purpose of the health record?

The primary purpose of a data set in healthcare is to:

Olivia is adopted, what is the best way to obtain a copy of Olivia's operative report?

Identify where the following documentation would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8":

The release of information function requires the HIM professional to have knowledge of:

The act of granting approval to healthcare organization based whether the organization met voluntary standards called:

Which of the following would be used to track data movement from one system to another?

The primary goal of Hospital Standardization Program, established in 1918 by the American College of Surgeons, was to:

What is the status conferred by a national professional org that is dedicated to a specific area of healthcare practice?

Authentication of a record refers to:

Which of the following is an example of clinical data?

Enterprise Information Management (EIM) functions is the overarching authority for managing organization's data assets?

A nurse is responsible for which the following types of acute-care documentation?

What type of health records may contain family and caregiver input?

Which of the following is not a characteristic of the common healthcare data set such as UHDDS and UACDS?

What types of covered entity health records are subject to the HIPAA privacy regulations?

When all required data elements are included in the health record, the quality characteristic for data ____ is met.

Which of the following individuals may authorize the release of health information?

Cancer registries receive approval as part of the facility cancer program from which of the following agencies?

What elements of coding quality represent the degree which codes accurately reflect patient's diagnoses and procedures?

HIM clerk finds requested records are stored off-site. How long is the hospital in compliance with HIPAA regulations?

Which of the following best describes data accessibility?

Which of the following is an individual user of the health record?

Admissions director maintain notice of privacy practices be provided to patient each admission. How HIM director respond

To respond to respond to subpoena ad testification, which of the following should the technician do?

The evaluation of data collection based on business needs and strategy is part of ______.

Which of the following contains the physician's findings based on an examination of the patient?

One department may use term "PATIENT" while another department may use the term "CLIENT" What standards should be used

Which of the following indexes is an important source of patient health record numbers?

In which of the following examples does the gender of the patient constitute information rather than a data element?

Ability to electronic send data from one information system to another while maintaining the original meaning is called:

A patient transitions from one care setting to another what core data ser developed by ASTM is used to see patients past