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AHIMA RHIA Exam Practice Questions (P. 2)

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Question #11
Joint Comission requires the attending physician to countersign health record documentation that is entered by
  1. A
    interns or medical students.
  2. B
    midwives.
  3. C
    consulting physicians.
  4. D
    physician partners.

Correct Answer:
A

Question #12
The minimum length of time for retaining original medical records is primarily governed by
  1. A
    Joint Commission.
  2. B
    medical staff.
  3. C
    state law.
  4. D
    readmission rates.

Correct Answer:
C

Question #13
The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar rmeasures might be utilized to govern the use of
  1. A
    fingerprint signatures.
  2. B
    voice recognition systems.
  3. C
    expert systems.
  4. D
    electronic signatures.

Correct Answer:
D

Question #14
Discharge summary documentation must include
  1. A
    a detailed history of the patient.
  2. B
    a note from social services or discharge planning.
  3. C
    significant findings during hospitalization.
  4. D
    correct codes for significant procedures

Correct Answer:
C

Question #15
The performance of ongoing record reviews is an important tool is ensuring data quality through accurate health records. These reviews evaluate
  1. A
    quality of care through the use of pre-established criteria.
  2. B
    adverse effects and contraindications of drugs utilized during hospitalization.
  3. C
    potentially compensable events.
  4. D
    completeness, adequacy, and quality of documentation.

Correct Answer:
D

Question #16
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
  1. A
    chief of staff.
  2. B
    attending physician.
  3. C
    HIM director.
  4. D
    risk manager.

Correct Answer:
B

Question #17
Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of
  1. A
    retrospective deficiency analysis.
  2. B
    special study audits.
  3. C
    concurrent chart review.
  4. D
    occurrence screening.

Correct Answer:
C

Question #18
The foundation for communicating all patient care goals in long-term care settings is the
  1. A
    legal assessment.
  2. B
    labor and delivery record.
  3. C
    interdisciplinary patient care plan.
  4. D
    Uniform Hospital Discharge Data Set.

Correct Answer:
C

Question #19
Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages?
  1. A
    Health Record Committee.
  2. B
    Utilization Review Committee.
  3. C
    Risk Management Committee.
  4. D
    Joint Conference Committee.

Correct Answer:
A

Question #20
A health record analyst needs to quickly compare all lab values during one hospitalization. The paper-based health record format best suited for this purpose is
  1. A
    problem-oriented.
  2. B
    source-oriented.
  3. C
    reverse chronological.
  4. D
    integrated.

Correct Answer:
B

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