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AHIMA RHIA Exam Practice Questions (P. 3)

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Question #21
In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of Him department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint
Commission standards your first recommended change is to
  1. A
    have more frequent committee meetings.
  2. B
    have the committee report to the Executive Committee.
  3. C
    have a physician perform all the reviews.
  4. D
    provide for record reviews to be performed by an interdisciplinary team of care providers.

Correct Answer:
D

Question #22
As the privacy officer of your facility, you have been charged with developing policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. One of the first steps you will take is to judge the value of information processed by your system and classify it.
Another step you will need to take is to
  1. A
    authorize access to information collected based on level of data sensitivity.
  2. B
    prevent all nonclinicians’ access to any confidential information in the system.
  3. C
    establish firewalls to protect aggregate data collected within your facility.
  4. D
    establish passwords for all customers, both internal and external, who request access to the information in your system.

Correct Answer:
A

Question #23
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1.
Which of the following statement regarding the history and physical is ture in this situation? Completion and charting of the H&P indicates.
  1. A
    noncompliance with Joint Commission standards.
  2. B
    compliance with Joint Commission standards.
  3. C
    compliance with Medicare regulations.
  4. D
    compliance with Joint Commission standards for nonsurgical patients.

Correct Answer:
A

Question #24
As your acute care facility moves toward the adoption of an HER, your planning committee is trying to prioritize systems that will contribnute to patient safety. Your physicians have indicated readiness to enter data directly into the HER, and they acknowledge the need for decision support regarding drug dosages and contraindications. You think they are ready for a
  1. A
    computer-output-to-laser-disk system.
  2. B
    electronic medication administration record system.
  3. C
    electronic document management system.
  4. D
    computerized provider order-entry system.

Correct Answer:
D

Question #25
You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?
  1. A
    disease index.
  2. B
    physician index.
  3. C
    master patient index.
  4. D
    operation index.

Correct Answer:
D

Question #26
The best example of point-of-care service and documentation is
  1. A
    using an automated tracking system to locate a record.
  2. B
    using occurrence screens to identify adverse events.
  3. C
    doctors using voice recognition systems to dictate radiology reports.
  4. D
    nurses using bedside terminals to record vital signs.

Correct Answer:
D

Question #27
Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to
  1. A
    placement of hospital logo.
  2. B
    signature line for authentication.
  3. C
    use of box design.
  4. D
    bar code placement.

Correct Answer:
D

Question #28
Which of the following is a form or view that is typically seen in the health record of a long-term care patient, but is rarely seen in records of a acute care patients?
  1. A
    pharmacy consultation.
  2. B
    medical consultation.
  3. C
    physical exam.
  4. D
    emergency record.

Correct Answer:
A

Question #29
One distinct advantage of the HER over paper-based health records is the
  1. A
    ease of developing screen designs over from designs.
  2. B
    accessibility of the record by multiple data users.
  3. C
    standardized format.
  4. D
    ease of data collection

Correct Answer:
B

Question #30
The first cancer patient seen in your facility on January 1, 2008, was diagnosed with colon cancer, with no known history of previous malignancies. Th eaccession number assigned to this patient is
  1. A
    2008-0000/00.
  2. B
    2008-0000/01.
  3. C
    2008-0001/00.
  4. D
    2008-0001/01.

Correct Answer:
C

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