RHIT Exam Questions and Answers, Exams of Advanced Data Analysis

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1. OASIS data are used to assess the ___ of home health services. - Correct answer Outcome
2. A statement or guideline that directs decision making or behavior is called a: - Correct answer Policy
3. Examples of high-risk billing practices that create compliance risks for healthcare organizations include all of the following, except: - Correct answer Returned Overpayments
4. Healthcare fraud is all of the following except: - Correct answer Unnecessary Costs to a program
5. Corporate compliance programs became common after adoption of which of the following: - Correct answer Federal Sentencing Guidelines
6. Which of the following is a legal concern regarding the EHR? - Correct answer Ability to subpoena audit trails.
7. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called: - Correct answer Accreditation
8. A group practice has hired an HIT as its chief compliance officer. The current compliance program includes written standards of conduct and policies and procedures that address specific areas of potential fraud. It also has audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? - Correct answer A hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation
9. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? - Correct answer Nursing Staff
10. Which of the following organizations within the federal government is responsible for looking at the issues related to the efficiency and effectiveness of the healthcare delivery system, disease protocols, and guidelines for improved disease outcomes? - Correct answer Agency for Healthcare Research and Quality (AHRQ)

11. Which of the following issues compliance program guidance? - Correct answer HHS Office of Inspector General (OIG)
12. Which of the following is an example of data security? - Correct answer Automatic logoff after inactivity
13. A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed? - Correct answer Retrospective Utilization Review
14. An EHR system can provide better security than a paper record for protected health information system due to: - Correct answer Access controls, audit trails, and authentication systems
15. Community Hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations? - Correct answer Each physician practice should obtain a business associate agreement with the hospital
16. Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits? - Correct answer The Joint Commission
17. Developing, implementing, and revising the organization's policies is the role of: - Correct answer Middle Managers
18. Position descriptions, policies and procedures, training checklists, and performance standards are all examples of: - Correct answer Staffing Tools
19. This organization has been responsible for accrediting healthcare organizations since the mid 1950's and determines whether the organization is continually monitoring and improving the quality of care they provide. - Correct answer The Joint Commission
20. Which of the following is a written description of an organization's formal position? - Correct answer Policy
21. The Deficit Reduction Act of 2005: - Correct answer Made compliance programs mandatory

22. Which of the following statements best defines utilization management? - Correct answer It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care
23. Which of the following is not a type of utilization review? - Correct answer Peer Review
24. Which of the following is not one of the basic functions of the utilization review process? - Correct answer Claims Management
25. The Medical Review Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM Director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the Committee conclude? - Correct answer Data are insufficient to determine whether the hospital is in compliance
26. Which of the following is the largest healthcare standards-setting body in the world? - Correct answer The Joint Commission
27. Which of the following is the largest healthcare standards-setting body in the world? - Correct answer The Joint Commission
28. Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise? - Correct answer City Hospital should obtain a business associate agreement with Community Hospital
29. Which of the following facilities do not have to meet standards in the Conditions of Participation? - Correct answer Physician Offices
30. An audit trail may be used to detect which of the following: - Correct answer Unauthorized access to system
31. Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called: - Correct answer Elements of performance
32. The creation of the National Practitioner Data Bank was mandated by the: - Correct answer Health Care Quality Improvement Act
33. Which of the following dictates how the medical staff operates? - Correct answer Medical Staff Bylaws

34. Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team? - Correct answer Chief Executive Officer
35. Medical school graduates must pass a test before they can obtain a _____ to practice medicine. - Correct answer License
36. Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity: - Correct answer Can deny access to psychotherapy notes.
37. In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information? - Correct answer When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual
38. Which of the following statements is true in regard to responding to requests from individuals for access to their PHI? - Correct answer A cost-based fee may be charged for making a copy of the PHI
39. Which of the following is not an automatic contgrol that helps preserve data confidentiality and integrity in an electronic system? - Correct answer Security Awareness programs
40. Within the context of data security, protecting data privacy means defending or safeguarding: - Correct answer Access to information
41. The protection measures and tools for safeguarding information and information systems is a definition of: - Correct answer Data Security
42. To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? - Correct answer Base charges on the cost of labor and supplies for copying and postage if copies are mailed
43. A risk analysis is useful to: - Correct answer Identify security threats
44. Which of the following is required by HIPAA standards? - Correct answer A written contingency plan

45. Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security? - Correct answer Administrative safeguards
46. What is the biggest threat to the security of healthcare data? - Correct answer Employees
47. To ensure relevancy, an organization's security policies and procedures be reviewed at least: - Correct answer Once a year
48. Which of the following is not true of good electronic forms design? - Correct answer Use radio buttons to select multiple items from a set of options
49. What committee usually oversees the development and approval of new forms for the health record? - Correct answer Use radio buttons to select multiple items from a set of options
50. The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria is: - Correct answer Utilization Review
51. Placing locks on computer room doors is considered what type of security control? - Correct answer Physical Control
52. Which of the following is recommended for design of forms for an EDMS? - Correct answer 24 lb. paper for double-sided forms
53. The HIM Supervisor suspects that a departmental employee is accessing the EHR for personal reasons but has no specific data to support this suspicion. In this case, what should the supervisor do? - Correct answer Ask the security officer for audit trail data to confirm or disprove the suspicion.
54. Coding policies should include which of the following elements? - Correct answer AHIMA Standards of Ethical Coding
55. The Medicare Integrity Program was established as part of Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities? - Correct answer Payment determinations and audit of cost reports
56. An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system? - Correct answer Role-Based
57. A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review

her health record. Of the options here, what is the best course of action? - Correct answer Allow her to review her record after obtaining authorization from her

58. St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. Of the options here, what is the best course of action? - Correct answer Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patient
59. Minors are basically deemed legally incompetent to access, use or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors? - Correct answer State law because HIPAA defers to state laws on matters related to minors
60. If an HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing: - Correct answer Fraud
61. What is the general name for Medicare rules affecting healthcare organizations?
    • Correct answer Conditions of Participation
62. The permanent RAC program was completely implemented in the United States by: - Correct answer January 2010
63. During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all system modules. For example, they have to use one log-on for CPOE and another log- on to view laboratory results. One physician suggest having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide? - Correct answer Single sign-on is less frustrating for the end user and can provide better security
64. Which of the following are security safeguards that protect equipment, media, and facilities? - Correct answer Physical Access Controls
65. What does the term access control mean? - Correct answer Identifying which data employees should have a right to use
66. Which of the following is a software program that tracks every access to data in the computer system? - Correct answer Audit Trail

67. All of the following are steps in medical necessity and utilization review, except: - Correct answer Access consideration
68. Which of the following can be used to discover current hot areas of compliance?
    • Correct answer The OIG workplan
69. In Medicare, the most common forms of fraud and abuse include all of the following, except: - Correct answer Implementing a clinical documentation improvement program
70. The one aspect of managed care that has had the greatest impact on healthcare organizations is: - Correct answer Cost Control
71. The policies and procedures section of a coding compliance plan should include all of the following except: - Correct answer Utilization Review
72. What is the term for an explicit statement that directs clinical decision making? - Correct answer Evidence-based practice guideline
73. Gatekeepers determine the appropriateness of all of the following components, except: - Correct answer Rate of capitation or reimbursement
74. Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are: - Correct answer Safe Harbors
75. How often are healthcare facilities required to practice their emergency preparedness plan annually? - Correct answer Twice
76. This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs. - Correct answer Commission on Accreditation of Rehabilitation Facilities
77. What is it called when accrediting bodies such as The Joint Commission can survey facilities for compliance with the medicare Conditions of Participation for Hospitals instead of the government? - Correct answer Deemed Status
78. Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients? - Correct answer Tracer Methodology
79. Which of the following services is most likely to be considered medically necessary? - Correct answer Standard of care for health condition

80. Case management coordinates an individual's care, especially in complex and high cost cases. Goals of case management include all of the following except: - Correct answer Information Security
81. When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with a(n) ____ indicating that Medicare might not pay and that the patient might be responsible for the entire charge. - Correct answer ABN
82. The number that has been proposed for use as a unique identification number but is controversial because of confidentiality and privacy concerns is the: - Correct answer Social Security Number
83. HIM Professionals have been working with a multidisciplinary committee to identify the best solution that will allow hospital physicians coordinated access to all forms of incoming and outgoing messages including voice, fax, e-mail, and video mail. Currently, physicians have to log in to various systems, using different IDs and passwords to retrieve all their messages, reducing effectiveness and efficiency. Which of the following would provide the best solution to the current problem? - Correct answer Computer-telephone integration (CTI)
84. The chief information officer is a senior-level executive who is responsible for: - Correct answer Leading the organization's strategic Information Systems planning process
85. Which of the following is not a true statement about a hybrid health record system? - Correct answer Version control is easy to implement
86. Which of the following would be the best course of action to take to ensure continuous availability of electronic data? - Correct answer Use mirrored processing on redundant servers
87. Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible? - Correct answer Electronic document management system
88. Which of the following technologies would be best for a hospital to use to manage data from its laboratory, pharmacy, and radiology information systems? - Correct answer Clinical data repository
89. Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users? - Correct answer Controlled Vocabulary
90. Why does an ideal EHR system require point-of-care charting? - Correct answer Ensures that appropriate data are collected

91. Which of the following is a transition strategy to achieve an EHR? - Correct answer Electronic document management system
92. To ensure that a computerized provider order entry (CPOE) system supports patient safety, what other system must also be in place? - Correct answer Pharmacy Information System
93. Which of the following is the unique identifier in the relational database patient table? - Correct answer Patient Number
94. As part of an EHR system selection, due diligence should be done: - Correct answer Before contracting for an EHR product
95. Which of the following tasks is not performed in an electronic health record system? - Correct answer Assembly
96. A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as: - Correct answer Implementation Plan
97. Which of the following is an application that uses standard order sets and other clinical decision support that supports physician order entry into the computer? - Correct answer CPOE
98. Electronic systems used by nurses and physicians to document assessments and findings are called: - Correct answer Electronic point-of-care charting
99. In the relational database shown here, the patient table and the visit table are related by: - Correct answer Patient Number
100. A key element in effective systems implementation is: - Correct answer User training
101. The director of health information services is allowed access to the medical record tracking system when providing the proper log-in and password. Under what access security mechanism is the director allowed access to the system? - Correct answer User-based
102. A special web page that offers secure access to data is a(n): - Correct answer Portal
103. When some computers are used primarily to enter data and others to process data the architecture is called: - Correct answer Client/server
104. The ability to electronically send data from one electronic system to a different electronic system and still retain its meaning is called: - Correct answer Interoperability

105. To effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standard? - Correct answer X12N
106. Who are the primary users of the health record for delivery of healthcare services? - Correct answer Clinical professionals who provide direct patient care
107. The vision of the EHR is that discrete data would be entered by providers into an EHR via: - Correct answer Templates
108. The key for linking data about an individual who is seen in a variety of care settings is: - Correct answer Identity Matching Algorithim
109. Which statement is true concerning CDR and EHR? - Correct answer CDR supports management of data for an EHR
110. The primary user of computerized provider entry is: - Correct answer Physician
111. One of the advantages of an EDMS is that it can: - Correct answer Help manage work tasks
112. Which of the following computer architectures uses a single large computer to process data received from terminals into which data are entered? - Correct answer Mainframe
113. A transition technology used by many hospitals is to increase access to medical record content is: - Correct answer Electronic document management system
114. When a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications, this is commonly referred to as a ____ strategy. - Correct answer Dual Core
115. Which of the following is not true about document imaging? - Correct answer Uses microfilm to store images
116. What type of information system would be used for processing patient admissions, employee time cards, and purchase orders? - Correct answer Transaction processing system
117. The first phase of the SDLC is the ____ phase. - Correct answer Planning

118. What basic components make up every electronic network communications system? - Correct answer Transmitters, receivers, media, and data
119. The concept of systems integration refers to the healthcare organization's ability to: - Correct answer Combine information from any system within the organization
120. The RFP generally includes a detailed description of the system's requirements and provides guidelines for vendors to follow in: - Correct answer Bidding for the contract
121. The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the ____ approach. - Correct answer Direct cutover
122. In which phase of the systems development life cycle is the primary focus on identifying and assigning priorities to the various upgrades and changes that might be made in an organization's information systems? - Correct answer Planning
123. In which phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users performed? - Correct answer Implementation
124. Which of the following is considered a consumer-centric informatics application? - Correct answer PHR
125. Which of the following best describes the function of kiosks? - Correct answer A computer station that promotes the healthcare organization's services
126. A medication being ordered is contraindicated due to a patient allergy. The physician is notified. This is an example of a(n): - Correct answer Alert
127. Which of the following systems would the HIM department director use to receive daily reports on the number of new admissions to, and discharges from, the hospital? - Correct answer Management information system
128. Which of the following is a snapshot in time and consolidates data from multiple sources to enhance decision making? - Correct answer CDW
129. Which of the following uses artificial intelligence techniques to capture the knowledge of human experts and to translate and store it in a knowledge base? - Correct answer Expert System

130. Which of the following stores data in predefined tables consisting of rows and columns? - Correct answer Relational database
131. Which of the following uniquely identifies each record in a database table?

- Correct answer Primary Key 

132. What is the purpose of computer databases? - Correct answer Store and retrieve data.
133. Which of the following is a technique for graphically depicting the structure of a computer database? - Correct answer Data Model
134. An organization identifies key people in various functional areas to be trained first, and then asks them to subsequently train other users in this same functional area. What is this approach to user training called? - Correct answer Train-the-trainer
135. Which of the following connects computers together in a way that allows for the sharing of information and resources? - Correct answer Network
136. Which of the following is considered a two-factor authentication system? - Correct answer Password and swipe card
137. Which of the following technologies would reduce the risk that information is not accessible during a server crash? - Correct answer Server redundancy
138. A system that enables processing of diagnostic studies results into tables, graphs, or other structure is: - Correct answer Results retrieval and management technology
139. Community Hospital's hardware has been placed on back-order; the network team is having trouble getting the network to function properly. This is an example of: - Correct answer Issues management
140. Audit logs and alert pop-ups are examples of: - Correct answer Metadata
141. Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices? - Correct answer HL
142. The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric: field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element? - Correct answer The field type should be changed to Character

143. Systems testing of a new information system should be conducted using: - Correct answer Actual Patient Data
144. Which of the following are used to associate relationships between entities (tables) in a relational database? - Correct answer Foreign Keys
145. Which of the following security controls are built into a computer software program? - Correct answer Application Controls
146. Community Hospital is identifying strategies to minimize the security risks associated with employees leaving their workstations unattended. Which of the following solutions will minimize the security risk of unattended workstations? - Correct answer Implement session termination
147. OASIS data are used to assess the ___ of home health services. - Correct answer Outcome
148. The Deficit Reduction Act of 2005: - Correct answer Made compliance programs mandatory
149. Which of the following statements best defines utilization management? - Correct answer It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care
150. Which of the following is not a type of utilization review? - Correct answer Peer review
151. Which of the following is not one of the basic functions of the utilization review process? - Correct answer Claims management
152. The Medical Review Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM Director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the Committee conclude? - Correct answer Data are insufficient to determine whether the hospital is in compliance
153. Which of the following is the largest healthcare standards-setting body in the world? - Correct answer The Joint Commission
154. Which of the following is the largest healthcare standards-setting body in the world? - Correct answer The Joint Commission
155. Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the

CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise? - Correct answer City Hospital should obtain a business associate agreement with Community Hospital

156. Which of the following facilities do not have to meet standards in the Conditions of Participation? - Correct answer Physician offices
157. An audit trail may be used to detect which of the following: - Correct answer Unauthorized access to a system
158. Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called: - Correct answer Elements of performance
159. The creation of the National Practitioner Data Bank was mandated by the:

- Correct answer Health Care Quality Improvement Act 

160. Which of the following dictates how the medical staff operates? - Correct answer Medical Staff Bylaws
161. Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team? - Correct answer Chief Executive Officer
162. Medical school graduates must pass a test before they can obtain a _____ to practice medicine. - Correct answer License
163. Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity: - Correct answer Can deny access to psychotherapy notes
164. In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information? - Correct answer When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual
165. Which of the following statements is true in regard to responding to requests from individuals for access to their PHI? - Correct answer A cost-based fee may be charged for making a copy of the PHI
166. Which of the following is not an automatic contgrol that helps preserve data confidentiality and integrity in an electronic system? - Correct answer Security awareness program

167. Within the context of data security, protecting data privacy means defending or safeguarding: - Correct answer Access to information
168. The protection measures and tools for safeguarding information and information systems is a definition of: - Correct answer Data Security
169. To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? - Correct answer Base charges on the cost of labor and supplies for copying and postage if copies are mailed
170. A risk analysis is useful to: - Correct answer Identify security threats
171. Which of the following is required by HIPAA standards? - Correct answer A written contingency plan
172. Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security? - Correct answer Administrative safeguards
173. What is the biggest threat to the security of healthcare data? - Correct answer Employees
174. To ensure relevancy, an organization's security policies and procedures be reviewed at least: - Correct answer Once a year
175. Which of the following is not true of good electronic forms design? - Correct answer Use radio buttons to select multiple items from a set of options
176. What committee usually oversees the development and approval of new forms for the health record? - Correct answer Use radio buttons to select multiple items from a set of options
177. The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria is: - Correct answer Utilization Review
178. Placing locks on computer room doors is considered what type of security control? - Correct answer Physical control
179. Which of the following is recommended for design of forms for an EDMS?

- Correct answer 24 lb. paper for double-sided forms 

180. The HIM Supervisor suspects that a departmental employee is accessing the EHR for personal reasons but has no specific data to support this suspicion. In this case, what should the supervisor do? - Correct answer Ask the security officer for audit trail data to confirm or disprove the suspicion.
181. Coding policies should include which of the following elements? - Correct answer AHIMA Standards of Ethical Coding
182. The Medicare Integrity Program was established as part of Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities? - Correct answer Payment determinations and audit of cost reports
183. An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system? - Correct answer Role- based
184. A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review her health record. Of the options here, what is the best course of action? - Correct answer Allow her to review her record after obtaining authorization from her
185. St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. Of the options here, what is the best course of action? - Correct answer Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patien
186. Minors are basically deemed legally incompetent to access, use or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors? - Correct answer State law because HIPAA defers to state laws on matters related to minors
187. If an HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing: - Correct answer Fraud
188. What is the general name for Medicare rules affecting healthcare organizations? - Correct answer Conditions of Participation

189. The permanent RAC program was completely implemented in the United States by: - Correct answer January 2010
190. During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all system modules. For example, they have to use one log-on for CPOE and another log- on to view laboratory results. One physician suggest having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide? - Correct answer Single sign-on is less frustrating for the end user and can provide better security
191. Which of the following are security safeguards that protect equipment, media, and facilities? - Correct answer Physical access controls
192. What does the term access control mean? - Correct answer Identifying which data employees should have a right to use
193. Which of the following is a software program that tracks every access to data in the computer system? - Correct answer Audit Trail
194. All of the following are steps in medical necessity and utilization review, except: - Correct answer Access consideration
195. Which of the following can be used to discover current hot areas of compliance? - Correct answer The OIG Workplan
196. In Medicare, the most common forms of fraud and abuse include all of the following, except: - Correct answer Implementing a clinical documentation improvement program
197. The one aspect of managed care that has had the greatest impact on healthcare organizations is: - Correct answer Cost control
198. The policies and procedures section of a coding compliance plan should include all of the following except: - Correct answer Utilization Review
199. The policies and procedures section of a coding compliance plan should include all of the following except: - Correct answer Evidence-based practice guideline
200. Gatekeepers determine the appropriateness of all of the following components, except: - Correct answer Rate of capitation or reimbursement

201. Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are: - Correct answer Safe Harbors
202. How often are healthcare facilities required to practice their emergency preparedness plan annually? - Correct answer Twice
203. This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs. - Correct answer Commission on Accreditation of Rehabilitation Facilities
204. What is it called when accrediting bodies such as The Joint Commission can survey facilities for compliance with the medicare Conditions of Participation for Hospitals instead of the government? - Correct answer Deemed Status
205. An HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process? - Correct answer Scanning all documents at the time of patient discharge
206. In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation would a coder look for to substantiate the diagnosis of aspiration pneumonia? - Correct answer Patient has history of inhaled food, liquid, or oil
207. Which of the following is an organization's planned response to protect its information in the case of a natural disaster? - Correct answer Business continuity plan
208. Which of the following is not a responsibility of a healthcare organization's quality management department? - Correct answer Conducting medical peer review to identify patters of care
209. Which of the following has the ultimate responsibility for ensuring quality in a healthcare facility? - Correct answer Board of Directors
210. The process that involves ongoing surveillance and prevention of infections so as to ensure the quality and safety of healthcare for patients and employees is known as: - Correct answer Infection Control
211. Every healthcare organization's risk management plan should include the following components except: - Correct answer Peer Review

212. Hospital A discharges 10,000 patients per year. Hospital B is located in the same town and discharges 5,000 patients per year. At Hospital B's medical staff committee meeting, a physician reports that he is concerned about the quality of care at Hospital B because the hospital has double the number of deaths per year than Hospital A. The HIM director is attending the meeting in a staff position. Which of the following actions should the director take? - Correct answer Suggest that the data be adjusted for possible differences in type and volume of patients treated
213. Which of the following provide process measure metrics in a precise format? - Correct answer Dashboard
214. Total quality management and continuous quality improvement are well- known: - Correct answer Performance improvement models
215. Donabedian proposed three types of quality indicators: structure indicators, process indicators, and: - Correct answer Outcome indicators
216. Many organizations and quality experts define quality as meeting or exceeding: - Correct answer Customer Expectations
217. Managing the adoption and implementation of new processes is called: - Correct answer Change management
218. How do health plans incentivize providers to use EHRs? - Correct answer Paying for performance programs
219. A key feature of performance improvement is: - Correct answer A continuous cycle of improvement
220. Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during performance improvement initiatives to facilitate ____ among employees. - Correct answer Communication
221. Periodic performance reviews: - Correct answer Encourage good performance
222. Which of the following is a data collection tool that records current processes? - Correct answer flow chart
223. According to the Pareto Principle: - Correct answer 20% of the sources of a problem are responsible for 80% of its actual effects

224. Change management is the process of planning for change. It concentrates on: - Correct answer Addressing employee resistance to changes in processes, procedures, and policies
225. Which of the following statements does not represent a fundamental principle of performance improvement? - Correct answer Systems are static and do not demonstrate variation
226. Which of the following should be the first step in any quality improvement decision-making process? - Correct answer Identifying the problem
227. As part of the clinic's performance improvement program, an HIM director wants to implement benchmarking for the transcription division at a large physician clinic. The clinic has 21 transcriptionists who average about 140 lines per hour. The transcription unit supports 80 physicians at a cost of 15 cents per line. What should be the first step that the supervisor takes to establish benchmarks for the transcription division? - Correct answer Clearly define what is to be studied and accomplished by instituting benchmarks
228. A record that fails quantitative analysis is missing the quality criterion of: - Correct answer Completeness
229. A report that lists the ICD-9-CM codes associated with each physician in a healthcare facility can be used to assess the quality of the physician's services before he or she is: - Correct answer Recommended for staff reappointment
230. When all required data elements are included in the health record, the quality characteristic for ____ is met. - Correct answer Data comprehensiveness
231. The sixth scope of work for quality improvement organizations (QIOs) introduced which of the following? - Correct answer Payment error Prevention Program
232. The following table compares Community Hospital's pneumonia length of stay (observed LOS) to the pneumonia LOS of similar hospitals (expected LOS). Given this data, where might Community Hospital want to focus attention on its pneumonia LOS? - Correct answer Family Practice
233. After an outpatient review, individual audit results by coder should become part of the: - Correct answer Individual employee's performance evaluation
234. The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data? - Correct answer Full- time coders are more productive than part-time coders

235. The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data? - Correct answer Full- time coders are more productive than part-time coders
236. The primary goal of the Hospital Standardization Program established in 1918 by the American College of Surgeons was to: - Correct answer Establish minimum quality standards for hospitals
237. A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome is a(n): - Correct answer Performance measure
238. A standard of performance or best practice for a particular process or outcome is called a(n): - Correct answer Benchmark
239. This type of performance measure focuses on a process that leads to a certain coutcome, meaning that a scientific or experimental basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome. - Correct answer Process Measure
240. Which of the following is not a step in quality improvement decision- making? - Correct answer Determination of the quickest solution
241. The principal process by which organizations optimize the continuum of care for their patients is: - Correct answer Case management
242. When the patient's physician contacts a healthcare organization to schedule an episode of care service, the healthcare organization begins which step in the case management process? - Correct answer Preadmission care planning
243. The National Patient Safety Goals (NPSGs) have effectively mandated all healthcare organizations to examine care processes that have a potential for error that can cause injury to patients. Which of the following processes are included in the NPSGs? - Correct answer Check patient medicines, prevent infection, and identify patients correctly
244. The interrelated activities in healthcare organizations, which promote effective and safe patient outcomes across services and disciplines within an integrated environment, are included in what area of performance measurement?

- Correct answer Processes 

245. A performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements is called: - Correct answer Indicator

246. This status is conferred by a national professional organization that is dedicated to a specific are of healthcare practice. - Correct answer Credential
247. The primary objective of quality in healthcare for both patient and provider is to: - Correct answer Arrive at the desired outcomes
248. Who is responsible for ensuring the quality of health record documentation? - Correct answer Provider
249. All of the following services are typically reviewed for medical necessity and utilization except: - Correct answer Well-baby check
250. A Joint Commission-accredited organization must review its formulary annually to ensure a medication's continued: - Correct answer Efficacy and Safety
251. Environmental assessments are performed as part of which of the following processes? - Correct answer Strategic planning
252. Which of the following actions is not included about a physician in the National Practitioner Data Bank? - Correct answer Personal bankruptcy
253. The Joint Commission's quality improvement activites for health record documentation include all but which of the following core performance measures for hospitals: - Correct answer Seizure disorder
254. This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans: - Correct answer HEDIS
255. In this case management step, the case manager confirms that the patient meets criteria for the care setting and that the services can be provided at the facility. - Correct answer Care planning at the time of admission
256. The final results of care, treatment, and services in terms of the patient's expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing, are included in what are of performance measurement? - Correct answer Outcomes
257. An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines is called: - Correct answer Standards of care

258. An HIM director reviews the departmental scanning productivity reports for the past three months and sees that productivity is below that of the national average. Which of the following actions should the director take? - Correct answer Investigate whether there are factors contributing to the low productivity that are not reflected in the national benchmarks
259. Through the establishment of the National Practitioner Data Bank (NPDB), the federal government became involved in malpractice issues and what other type of issue? - Correct answer Quality of care
260. All of the following are Joint Commission core measure criteria sets except: - Correct answer Diabetes mellitus
261. During training, the employee should be: - Correct answer Evaluated to make sure work is error free
262. A coding supervisor who makes up the weekly work schedule would engage in what type of planning? - Correct answer Operational
263. Performance standards are used to: - Correct answer Communicate performance expectations
264. A supervisor wants to determine whether the release of information staff are working at optimal output. Which of the following would be most useful to determine this? - Correct answer Set productivity standards for the area and review results on a regular basis
265. I reviewed the patient's record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This would be an example of: - Correct answer Quantitative analysis
266. I reviewed the health record of Sally Williams and found the physician stated on her post-op note, "examined after surgery." This would be an example of: - Correct answer Qualitative Analysis
267. Attorneys for healthcare organizations use the health record to: - Correct answer Protect the legal interests of the facility and its healthcare providers
268. Under HIPAA, which of the following is not named as a covered entity? - Correct answer Outsourced transcription company
269. The HIPAA Privacy Rule: - Correct answer Sets a minimum (floor) of privacy requirements

270. Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule? - Correct answer Contained within a personnel file
271. Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule? - Correct answer Contained within a personnel file
272. Which of the following is not an identifier under the Privacy Rule? - Correct answer Age 75
273. Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true? - Correct answer The Privacy Rule's minimum necessary requirement does not apply
274. Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a(n): - Correct answer Workforce member
275. Lane Hospital has a contact with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linen for off-site laundering, Ready- Clean is: - Correct answer Not a business associate because it does not use or disclose individually identifiable health information
276. Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is: - Correct answer Not protected by the Privacy Rule because it is part of a personnel record
277. The HIPAA Security Awareness and Training administrative safeguard requires all of the following addressable implementation programs for an entity's workforce except: - Correct answer Disaster recovery plan
278. Burning, shredding, pulping, and pulverizing are all acceptable methods in which process? - Correct answer Destruction of paper-based health records
279. Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment? - Correct answer Document name, media type, source system, electronic storage start date, stop printing start date
280. The __ provide the objective and scope for the HIPAA Security Rule as a whole. - Correct answer General Rules
281. Which of the following must covered entities do to comply with HIPAA security provisions? - Correct answer Establish a contingency plan

282. For HIPAA implementation specifications that are addressable, which of the following statements is true? - Correct answer The covered entity must conduct a risk assessment to determine whether the specification is appropriate to its environment
283. The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wishes to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: - Correct answer Business records exception
284. From an evidentiary standpoint, incident reports: - Correct answer Should not be placed in a patient's health record
285. A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes: - Correct answer Spoliation
286. Authentication of a record refers to: - Correct answer Establishment of its baseline trustworthiness
287. When served with a court order directing the release of health records, an individual: - Correct answer Must comply with it
288. The following step should not be included in a health information department's procedure for preparing health records in response to a subpoena:

- Correct answer Remove pages containing detrimental information 

289. Written or spoken permission to proceed with care is classified as: - Correct answer Expressed Consent
290. To be in compliance with HIPAA regulations, a hospital would make its membership in a RHIO known to its patients through which of the following? - Correct answer Notice of Privacy Practices
291. Law enacted by a legislative body is a(n): - Correct answer Statute
292. What is the legal term used to describe the physical and electronic protection of health information? - Correct answer Security
293. The "custodian of health records" refers to the individual within an organization who is responsible for the following action(s),except: - Correct answer Testifies regarding the care of the patient