RHIT Exam Review: Questions &
Answers
The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be the best first step to help improve physician documentation?(Ans- Determine the type and volume of documentation problems
This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation.(Ans- Voluntary review
Healthcare facilities must have processes in place to maintain and correct the master patient index (MPI) against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Which of the following is used to match patients so that patient information can be merged?(Ans- Algorithm
A hospital interested in finding out if a physician has any adverse licensure
actions should review data from:
(Ans- NPDB (National Practitioner Data Bank)
was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical malpractice payments, adverse licensure actions, and certain professional review actions (such as denial of medical staff privileges) taken by healthcare entities such as hospitals against physicians, dentists, and other healthcare providers as well as private accrediting organizations and peer review organizations (Sharp 2016, 185).(Ans- NPDB (National Practitioner Data Bank)
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Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list?(Ans- It applies to orders and medication-related documentation
The HIM professional is arguing against the use of the copy/paste function in the EHR. Which of the following would be the position for this argument?(Ans- I am unable to identify the author.
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a (Ans- concurrent review
When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is determined by (Ans- Clinical privileges
Which database must a healthcare facility query as part of the credentialing process when a physician initially applies for medical staff privileges?(Ans- NPDB (National Practitioner Data Bank)
The process in which a healthcare organization addresses the provider documentation issues that are conflicting, ambiguous, or incomplete is called (Ans- Querying
In determining the data collection requirements for Medicare and Medicaid patients in a long-term care facility, the health information technician would consult standards from (Ans- CMS (Centers for Medicare and Medicaid Services)
Where in an acute care health record would the documentation "Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN." be found?(Ans- Physician Orders
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Information collected in a cancer registry typically includes:
(Ans- Type and stage of cancer and patient demographic information
Which of the following is a key feature of a problem-oriented health record?(Ans- Itemized list of patient's present and past conditions
Which of the following is the key to the identification and access of a patient's health record?(Ans- Master Patient Index (MPI)
In performing quantitative analysis of an emergency room health record, which of the following data elements would the health information technician look for to be present in the record?(Ans- Patient identification, time and means of patient arrival, pertinent history of illness
When managing the master patient index (MPI) which of the following would be the biggest concern for the health information technician?(Ans- Duplicate health record numbers
Where would you expect to find the following documentation in the health
record: "BUN 14, Creatinine 0.9, H&H 8.8 and 25.4?"
(Ans- laboratory report
Reviewing a health record for missing signatures and medical reports is called (Ans- analysis
Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record?(Ans- ambulatory record
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