Download RHIT EXAM STUDY GUIDE (SAYLES) and more Exams Medicine in PDF only on Docsity!
RHIT EXAM STUDY GUIDE (SAYLES)
The hospital standardization movement was inaugurated by the: - American College of Surgeons The HIM profession is changing due to: - Changes in technology The new model of HIM practice is: - Information focused The traditional model of HIM practice was: - Department based The organization that accredits HIM education programs is: - CAHIIM Our college has applied to become accredited by CAHIIM. Which of the following is the name of the interim stage of accreditation? - Candidacy f the following is the virtual network used by AHIMA members? - Engage Which of the following functions governs the HIM profession? - House of Delegates The primary focus of AHIMA is to: - Foster professional development of it's members. Which of the following certifications is administered by CCHIIM? - Registered Health Information Technician The acronym IDS refers to: - Integrated Delivery Systems Which healthcare professional assists physicians in clinical assessments and patient education? - Physician assistant Which of the following medical practitioner is not considered a generalist? - Cardiology Which of the following laws created the HITECH Act? - American Recovery and Reinvestment Act
An HIM student has asked you why Medicare reimburses healthcare providers through prospective payment systems. Which of the following pieces of legislation would you use as your explanation? - Tax Equity and Fiscal Responsibility Act of 1982. Which of the following legislation authorized the creation of the Office of National Coordinator for Health Information Technology? - ARRA Required that hospitals conduct continued-stay reviews for Medicare and Medicaid patients. - Utilization Review Act of 1977 Required concurrent review of Medicare and Medicaid patients. - Public Law 92-603 of 1972 Provided an individual mandate to have minimum acceptable coverage or pay a tax penalty. - Patient Protection and Affordable Care Act of 2010 Gave the states funds on a matching basis for maternal and infant care, rehabilitation of crippled children, general public health work, and aid for dependent children under age 16. - Social Security Act of 1935 Required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement. - Tax Equity and Fiscal Responsibility Act of 1982 Which of the following is NOT an example of an administrative support services? - HIM Who has the primary responsibility to guide the direction of the hospital? - Board of Directors Which of the following is an example of a federally run hospital? - VA Dr. Smith has been granted permission by community hospital to perform cardiac catherizations. This permission is called? - Clinical privileges True/False: Acute-care hospitals provide short0term care to diagnose or treat an illness. - TRUE Ture/False: Pharmaceutical services are considered part of the clinical support services. - TRUE True/False: The average length of stay for an acute-care hospital is 25 days or less. -
Which federal agency monitors healthy precautions for international travelers? - CDC Which of the following documents from the National Academy of Medicine addressed the duplication and contrasting approaches to performance measures by the six major governmental healthcare programs that serve nearly 100 million Americans? - Leadership by Example True/False: There are six federal agencies that provide healthcare to over 100 million people. - TRUE True/False: The American healthcare system is not developed from a master plan but is instead a patchwork quilt of measures passed not from thought as to how it would affect the whole, but rather based on idiology. Much attention today is focused on the cost of healthcare often at the expense of patient access and the quality of care provided. - TRUE True/False: Healthy People 2020 is the third iteration of this discount. - TRUE True/False: Comparative effectiveness research is a major focus of the Patient-Centered Outcomes Research Institute. - TRUE An example of a the primary purpose of the health record. - Patient care What organization utilizes health record data to prove or disapprove the efficacy of a healthcare treatment? - Research Which of the following is an example of an institutional user of the healthcare? - Third party payer Which of the following is an example of an individual user? - Patient Health departments use the health record to monitor outbreaks of diseases. Which type of use is this? - Public health and research What microfilm format is inefficient when patients have multiple admissions on microfilm? - Roll What type of paper-based storage system conserves floor space by eliminating all but one or two aisles? -
Mobile filing units What feature of the filing folder helps locate misfiles within the paper-based filing system? - Color coding Which of the following is a tool used to track paper-based health records? - Outguide What should be done when the HIM departments error or accuracy rate is too high based on policy? - Corrective action should be taken. In a paper-based system, individual health records are organized in a standardized order in which of the following processes? - Assembly Reviewing a health record for missing signatures and missing medical reports is called - Analysis Two patients' records were filed together by mistake. This is an example of: - Overlay Which of the following describes incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies? - Delinquent records One of the advantages of a DMS is that it can: - Control workflow How are amendments handled in the EHR? - The amendment must have a separate signature, date, and time. Version control of documents in the EHR requires: - Policies and procedures to control which version(s) is displayed. Which of the following is controlled by the patient? - Personal health record Where will you find clinical decision support? - Electronic health record Which of the following systems is used to track whether or not a request for information has been processed? - Release of information
Which group focuses solely on accreditation of rehabilitation programs and services? - CARF Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient? - Emergency care A patient's registration forms, property list, RAI, care plan, and discharge or transfer for documentation would be found most frequently in which type of health record? - Long term care Which of the following would not be found in a physical exam? - General condition Written or spoken permission to proceed with care is classified as: - Expressed content Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? - Care plan A growth and development record may be found in what type of record? - Pediatric True/False: Many services such as surgery, infusions, and other diagnostic procedures that once required over night hospital stay for the patient, no longer requires that level of care. - TRUE True/False: CMS requires that healthcare providers inform their patients about general patient rights afforded to them. - TRUE True/False: Healthcare provider organizations normally have patients sign an acknowledgement acknowledging that the healthcare provider organization is not responsible for the loss of or damage to the patient's valuables. - TRUE The subjective, objective, assessment plan (SOAP) method came from the: - Problem-oriented health record Which of the following electronic record technological capabilities would allow paper-based health records to be incorporated into a patient's EHR? - Documentation-imaging technology The problem list is part of which of the following? - Problem-oriented health record.
The paper health record has been scanned and is now available digitally. What is this known as?
- It is known as imaging. Nursing documentation within the health record will be: - Objective True/False: Payers and the government are not concerned with how a physician documents in a health record. - FALSE True/False: Only physicians document in the health record. - FALSE True/False: HIM professionals document in the health record. - FALSE True/False: Management of health record information is a fundamental component of information governance. - TRUE True/False: If data granularity is the goal of collecting the data, clinical terminologies is the best choice. - TRUE True/False: The SNOWMED CT preferred term includes the semantic tag. - TRUE True/False: The three main core components of SNOWMED CT are concepts, descriptions, and relationships. - TRUE True/False: Category I CPT includes E/M, anesthesia, surgery, radiology pathology and laboratory, and medicine. - TRUE True/False: The purpose of nursing terminologies is to represent clinical information generated and used by nursing staff. - TRUE Which of the following is standard for drugs under the Meaningful Use program? - RxNorm Which of the following is standard for supplies under HIPAA? - HCPCS
What is a database? - A collection of data organized in such a way that its contents can be easily accessed, managed, reported and updated. True/False: There is usually only one source of data within a healthcare organization. - FALSE What is data stewardship? - Creates responsibility for data through principles and practices to ensure the knowledgeable and appropriate use of data derived from individuals' personal health information. What are the benefits of data stewardship? - Improved access, alerts, reminders, rapid access, facilitates coordination of care, structured data collection, comprehensive data and supports research and well as disease prevention and control. What is data integrity? - The assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. What is interoperability? - The capability of two or more information systems and software applications to communicate and exchange information. What are SDOs? - Standards development organizations which are private or government agencies that are involved in the creation and implementation of healthcare standards. What are data interchange standards? - These are standards that are developed in order to support and create structure with data exchange to sustain interoperability. SDO's are managed by: - The American National Standards Institute (ANSI) Information assets refer to: - Information collected during day-to-day operations of a healthcare organization that has value within an organization. Enterprise information management is: - The set of functions created by an organization to plan, organize, and coordinate the people, processes, technology and content needed to manage information for the purposes of data quality, patient safety and ease of use.
True/False: AHIMA and data governance is an essential component of daily operations, the ability to understand, evaluate, and apply the different principles becomes an essential part of a successful information and data governance program. - TRUE Which program was used to raise the standards of surgery by establishing minimum quality standards for hospitals? - American College of Surgeons (ACS) Accreditation programs are managed by: - Commission on Accreditation for Health Informatics and Information Education (CAHIM) What is information governance? - The accountability framework and decision rights to achieve enterprise information managment. AHIMA's (blank) leads the volunteer structure and also is responsible for managing the association and determining direction and ensuring that the organization is fiscally sound. - Board of directors This is a not-for-profit organization who is focused on better health through information technology (IT). - Healthcare Information and Management Systems Society (HIMSS) Who educates and certifies medical coders? - American Academy of Professional Coders (AAPC) This places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialist and ancillary providers. - Continuum of care An (blank) comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to deliver health services. - Integrated Delivery Networks (IDNs) A type of healthcare organization that delivers medical care and manages all aspects of patient care or the payment for care by limiting providers of care, discounting payments to providers of care, or limiting access to care. - Managed care organizations (MCOs) This is the process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified. - Utilization review (UR)
Alphanumeric filing system All of the patient's encounters are filed together in a single location. - Centralized unit filing systems Monitoring the quality of documentation. - Qualitative analysis The process of ensuring that each page in the health record is organized in a standardized format.
