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RHIT Study
| Question | Answer |
|---|---|
| Marge Voltz was treated in the hospital for varicose veins and was discharged 5/13. After returning to work full time, she developed complications and was readmitted on 6/9 for additional treatment of this painful condition. Her attending physician should | interval history and physical |
| Written authorization for release of information from a deceased patient’s record would be signed by the _____. | executor of the estate |
| Authority delegated to a subordinate should be commensurate with _____. | responsibility |
| The census taken at midnight August 21 indicated that there were 186 patients remaining in the hospital. On August 22, 13 adults and children were admitted and ten patients were discharged. Calculate the daily inpatient census for August 22. | 189 |
| A subpoena duces tecum on an inpatient record for which there are no previous hospitalizations is received by the health information department. Department processing would result in _____ | contacting the judge to suggest that a copy of the inpatient record be sent |
| The exchange of health information electronically between providers and others with the same level of interoperability is known as ________________. | health information exchange |
| Predetermined elements against which aspects of quality of care may be measured are called | criteria |
| In order to be within CMS compliance, a patient's medical history must be completed no more than _____ days from the date of admission. | 30 |
| Review the following MS-DRG table and choose the most correct statement: MS-DRG Description Weight 192 Chronic Obstructive Pulmonary Disease w/o CC/MCC 0.712 193 Simple pneumonia w MCC 1.455 | The higher the MS-DRG weight the more healthcare resources are required |
| Code the following scenario: Patient readmitted today with complaints of fever, nausea, vomiting, foamy urine; appeared acutely ill. She was discharged last week after left total knee joint replacement surgery during which she received 2 units of blood. | B16.1 J44.0 |
| A coding supervisor has received permission to expand her unit by one extra person. She has a small, but steady, backlog of discharged records to be coded. Her coders, all excellent employees, handle all of the functions of the unit, including answering t | analysis clerk |
| The HIM director is concerned about backlogs occurring in the technical area. Which management tool would the director utilize to determine the amount of time employees currently spend on various activities? | work distribution chart |
| Under the inpatient prospective payment system, cases with very high costs are called _____. | outliers |
| A hospital rendered a total of 57,325 service days to adult inpatients during the past year. It maintained a bed capacity of 250, except during January through March when a 125-bed wing was closed for alterations. Rounding off to a whole number, calculate | 73 |
| In computing the infection rate, the ratio is that of infections to _____. | total discharges |
| An original data source where the data are documented or collected by the provider of care is known as a ________ data source. | primary |
| The medical transcription unit is open Monday through Friday during the day. It is responsible for transcribing an average of 200,000 lines of dictation in each four-week period. The transcription minimum productivity standard for this unit is 1,000 lines | 10 |
| The Medical Center discharged 1,300 adult and child patients and 40 newborns during September. Total discharge days for these discharged patients was 11,500 for the adults and children, and 270 for the newborns. The formula for the average duration of inp | 11,500 ÷ 1300 |
| A physical examination includes documentation of _____ | how the eyes reacted to light |
| The release of information from records at an alcohol-drug abuse center is _____. | governed by federal regulations |
| The patient is seen in the office with abdominal pain. Upon evaluation, the physician determines that the following diagnoses need to be ruled out: appendicitis, cholecystitis, and pancreatitis. The doctor arranges for inpatient admission. The first-liste | abdominal pain |
| Relevant findings from QM activities must be considering during the _____. | reappraisal/reappointment of medical staff members |
| DRG Relative Weight Increase data in the table below indicates that 28% of cases resulted in a change in the coding of principal diagnosis and/or secondary diagnoses upon record review. This means that the healthcare facility received _______________. | additional reimbursement for recoded diagnoses and recalculated DRGs |
| A computer program which uses clinical information to assign inpatients to DRGs is called a(n): | grouper |
| Under the Health Care Quality Improvement Act of 1986, which database was created to identify medical malpractice payments? | National Practitioner Data Bank (NPDB) |
| As director of the health information management department, you manage the department through four (4) supervisors who collectively supervise all of the department’s functions. One day you notice a senior coder quickly code a discharged patient’s record | coder’s supervisor |
| Code the following scenario: Allergic reaction to penicillin (initial encounter). | T36.0x5A |
| An information technology department’s systems manager is alerted that unauthorized access to a computer is being attempted by routine _____ procedures. | surveillance |
| Finding easier/better ways to perform work is called work _____. | simplification |
| The basic tool or control mechanism used in risk management is the __________. | incident report |
| Determining whether services provided to a patient are appropriate for the patient's current or proposed level of care is called _______. | intensity of services |
| Which is the correct sequence for performing a quality management study? | Select topic, draft criteria, review charts, identify problems, implement solution |
| A patient was admitted with acute myocardial infarction, and the physician noted in the history and physical exam that the patient was status post cholecystectomy and had been hospitalized one year previously for pneumonia as well as asthma. No mention of | acute myocardial infarction |
| Nancy is the health information technician who performed analysis on charts of patients discharged the previous day. To be sure she had all of the discharged patient charts, she needs to _____. | obtain the admission/discharge list |
| The part of the computer that contains instructions for storing, manipulating, and retrieving data is called a _____. | software program |
| Current MS-DRG 266 has a weight of 8.7974, and New MS-DRG 219 has a weight of 7.9191. This means that reimbursement to the healthcare facility __________. | decreases |
| During the trial, a jury decides questions of _____. | evidence |
| Identify which of the following are the four data quality management domains. | Application, collection, warehousing and analysis |
| Code the following scenario: A 99-year-old male pulled Foley out at nursing facility; staff unable to reinsert. Blood at urethral meatus following this revealed laceration of urethra (initial encounter). Negative otherwise. Patient transported to hospita | S37.33xA, N39.0, I50.22 |
| A court-ordered subpoena duces tecum issued to a hospital is signed by the _____. | judge |
| The health information management department in a 700 bed university health care setting provides access to records 24 hours/day, seven days/week. To best secure the filing area and continue to maintain accessibility, the director of the health informatio | staff the area with file clerks on all 3 shifts |
| The mode of 17, 23, 94, 46, 94, 52, and 25 is _____. | 94 |
| Which has the final responsibility for the completion and accuracy of the patient record? | attending physician |
| Who owns the health record? | Provider who generated the information |
| As audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: | Granularity |
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