RHIT Mock Exam 100% Verified Answers 2024/2025, Exams of Nursing

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Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Baker (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should document discharge instructions in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record. Johnston City was set upon by a swarm of killer bees. All 5,000 residents are at risk of a bee attack. If 25 residents were attacked by the bees, the incidence of bee attacks is 5 in 1,000. Delinquent Rate Number of delinquent records/monthly discharges X 100 A supervisor reviews a job to determine the required content, skills, knowledge, abilities, and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job description A piece of objective data collected upon initial assessment of the patient is the vital signs. Which of the following is considered a late effect regardless of time? nonunion The purpose of CMS's National Correct Coding Initiative is to

detect and prevent payment for improperly coded services. Which of the following scenarios identifies a pathologic fracture? compression fracture of the vertebrae as a result of bone metastasis The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered an inappropriate use of hospital resources. A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of respondeat superior. Community Hospital Administration decided to change the number of adult and children beds from 300 to 375 effective on the first day in July. The total number of inpatient service days for adults and children for the year was 111,963. What was the percentage of occupancy rate for adults and children for the entire year? 90.8% (Total inpatient service days for a period/ total bed count days in a period X 100) You supervise five clerical employees who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for 300 square feet of space for your clerical staff. The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use

accession register. Incomplete abortion complicated by excessive hemorrhage; dilation and curettage performed. O03.1, 10D17ZZ A 4-year-old child had a repair of an incarcerated inguinal hernia. This is the first time this child had been treated for this condition. 49501 A patient initially consulted with Dr. Vasseur at the request of Dr. Meche, the patient's primary care physician. Dr. Vasseur examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vasseur's office for continuing care would be assigned from which E/M section? office and other outpatient services, established patient You are the office manager at a large group practice. One of the physicians at your practice has asked you to research and supply her with information about Medicare's newest payment incentives and how to comply with the quality reporting requirements. You will bring this inquisitive physician facts from CMS regarding Merit-based Incentive Payment System (MIPS) 1=Strongly disagree 2=Disagree 3=No opinion 4=Agree 5=Strongly agree The data collected using this scale are commonly referred to as ordinal data. A patient has written to request a copy of his own record. When the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. You advise the clerk to contact the patient's attending physician before complying.

The census taken at midnight on January 1 showed 99 patients remaining in the hospital. On January 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on January 2? 97 You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. You already have the relative value unit figure. The system you are likely referencing is RBRVS. In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to quality review committees within the hospital. In this case, the PHI is being used as part of the facility's health care operations. You are implementing a quality improvement plan that utilizes the PDSA cycle. If you correctly implement PDSA, which phase of the project will take the most of your time? P Four patients were discharged from Crestview Hospital yesterday. A final progress note is an appropriate discharge summary for Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. The coder works 7.5 hours per day. If a time standard is determined from sample observations to be 2.50 minutes per record for coding emergency room records, what is the daily standard for the number of records coded when a 15% fatigue factor is allowed? 153 records per day An established patient was seen by the physician in the office for DTaP vaccine and Hib. 90471, 90748

Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA Privacy Rules? Do not honor because the authorization is invalid. A clerk's work performance has diminished dramatically during the past 2 weeks. The supervisor initiates a discussion with the clerk, during which the clerk reveals that he recently accepted that he has an alcohol addiction. The clerk states an intention to quit drinking completely. The supervisor should refer the clerk to the facility's employee assistance program. Fred is recovering nicely, so he asks Dr. Jones if he can go home for the weekend. Dr. Jones approves a two-night leave of absence (LOA). Fred stays one more week before final discharge. How will this affect the hospital's statistics for the period when Fred was hospitalized? Fred's LOA will not negatively impact his total discharge days. As a new HIM manager, you recognize that employee development is a necessary investment for the long-term survival and growth of the organization. Your goal is to design and implement a staff development program for your employees, so one of your first steps is to survey the HIM employees to assess their need for new skills or knowledge. A patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of 47 days. Which of the following is coded as an adverse effect in ICD- 10 - CM? tinnitus due to allergic reaction after administration of eardrops The file clerks in your department's main file area report that they are able to locate 400 out of 450 requested records during the past month. There are a total of 4,500 records in the main file. What is the area's accuracy rate? 88.9% (Number of records filed correctly/ Number of records filed X 100)

An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done? Both patients can be treated under implied consent. A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? "N" Sunset Beach Clinic allows patients to communicate by email to ask questions regarding their treatment and request appointment changes. Emails and text messages are considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters. improve your department's processes. The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. The first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. For this information, you will consult the hospital bylaws, rules, and regulations. You are the Director of Coding and Billing at a large group practice. The practice manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt Promoting Interoperability (formerly Meaningful Use) technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that in 2015, sanctions for noncompliance began to appear in the form of downward adjustments to Medicare reimbursement. Which of the following diagnoses or procedures would prevent the normal delivery code, O80, from being assigned?

low forceps Collins Family Hospital had a bed count of 150 for the first 6 months of the year. On June 1, it added 15 beds when it opened a new wing. If you are given the average length of stay for the year, can you calculate the annual bed turnover rate? How? No, there is insufficient data to complete the calculation. A patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist. 77263 Office visit for 43-year-old male, new patient, with no complaints. Patient is applying for life insurance and requests a physical examination. A detailed health and family history was obtained and a basic physical was done. Physician completed life insurance physical form at patient's request. Blood and urine were collected. 99450 A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect these data would be check sheet. If the same condition is described as both acute and chronic and separate subentries exist in the ICD- 10 - CM alphabetic index at the same indentation level they should both be coded, acute sequenced first. As the information security officer at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. Which of the following would you provide? acceptable policies regarding workstation use and location Patient was seen for excision of two interdigital neuromas from the left foot. 28080, 28080

Your HMO manager has requested a report on the number of patient visits per year for preschool children. Which of the age groupings below will you use for your report? <12 months12-24 months25-37 months38-50 months51-63 months The correspondence section of your department receives an average of 50 requests per day for release of information. It takes an average of 30 minutes to fulfill each request. Using 6. productive hours per day as your standard, calculate the staffing needs for the correspondence section. 4 FTE A quantitative drug assay was performed for a patient to determine digoxin level. 80162 A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records? the patient You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM-5 for billing purposes. You find this "theoretically" reasonable because DSM- 5 codes are also valid ICD- 10 - CM codes. The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to let the administrative departmental staff get training. This will not do because it violates Joint Commission standards and CQI philosophy. The MS-DRG weight in a particular case is 2.0671 and the hospital's payment rate is $3,027. How much would the hospital receive as reimbursement in this case? $6,257.

The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. The coder would assign a code for a myocardial infarction. In preparing the retention schedule for health records, the most concrete guidance in determining when records may be destroyed will be the statute of limitations in your state. ORYX is a program that was developed by Joint Commission to link patient outcomes to accreditation. Provide the CPT code for anesthesia services for the transvenous insertion of a pacemaker. 00530 As a coder for a large physician practice, you have reason to believe that several physicians are involved in charging Medicare for services not rendered. Regulatory oversight for complaints regarding this fraudulent activity lies with the Recovery Audit Contractor. An HIM Department Budget Report for May shows a payroll budget of $25,000 and an actual payroll expense of $22,345. The percentage of budget variance for the month is 11%. CDI programs have been traditionally measured by financial data from DRG shifts and the shift in the organization's case-mix index. As CDI has grown, additional measures of success have been utilized. Which of the following items is not a measure of success for a CDI program? Bed occupancy rate A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) analyst.

relational data model A two-dimensional table representation of data; each row represents a unique entity (record) and each column is a field where record attributes are stored. Which of these conditions are always considered "present on admission" (POA)? congenital conditions As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee- for-Service program. You will need to develop a professional relationship with recovery audit contractors. A common goal of the Office of the National Coordinator for Health Information Technology, HIEs, and a national infrastructure for information is sharing information among providers. Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the UHDDS Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes. K80.10, I66.9, Z53. A number of key elements for your facility's electronic patient record are still input by clerical staff from handwritten data entry sheets. You are concerned about the transfer of data. If the vital signs stored in the database are not what were originally recorded, the impact on patient care could be severe. You are concerned about the validity of the data.

The Systems Development Life Cycle (SDLC) consists of four primary phases. Defining system goals, defining project objectives and scope, and determining and prioritizing the system requirements are part of which phase? Maintenance and Evaluation Annual costs for the only Release of Information Clerk at Jacksonville Beach Healthcare Center (salary and benefits) are $36,429. The monthly cost for the copier used solely for ROI is $ (supplies and repairs). It costs the department $0.95 on average for ROI mailings (envelopes and postage). There were 687 requests filled for ROI last month. The cost per request for release of information last month was $5.50. An Electronic Document Management Systems (EDMS) allows you to digitize paper patient records so that they can be viewed within the EHR or in a separate viewing platform. Documents are scanned in to the EDMS and indexing is completed through recognitions systems. Which of the following recognition systems utilizes artificial intelligence to allow the system to "learn" the form type through the handwriting or information on the form? IWR The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school. An effective means of protecting the security of electronic health information would be to develop clear policies on data security that are supported by the top management of the facility. In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the use of prohibited or "dangerous" abbreviations.

A patient's husband slipped and fell in your HIM reception area and now he is suing the facility. You have been asked to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on interrogatories A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that you are opposed to the union. A run or line chart would be most useful for collecting data on waiting time in the Pediatrics Clinic over a 6-month period. Patient was seen in the Emergency Department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures. 12035 The special form or view that plays the central role in planning and providing care at skilled nursing, psychiatric, and rehabilitation facilities is the interdisciplinary patient care plan. Generally, CMS requires the submission of a claim (CMS 1450) for inpatient services provided to a Medicare beneficiary for inpatient services. An exception to this requirement would be when the beneficiary refuses to authorize the submission of a bill to Medicare. Which of the following responsibilities would you expect to find on the job description of a facility's chief security officer but NOT on the job description of chief privacy officer? Conduct audit trails to monitor inappropriate access to system information. Vaginal delivery with episiotomy of full-term live-born infant. Patient undergoes repair of delivery episiotomy and postdelivery elective vaginal endoscopic ligation of fallopian tubes bilaterally. O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ

Release of information has increased its use of part-time PRN clerical support in order to respond to increased requests for release of information in a timely manner. For the line item projecting costs for ROI, this quarter's budget variance report will reflect the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. The ER staff has collected the data on the number of visits and corresponding wait times in the ER. The data are displayed on the chart shown above. Based on this information, what kind of correlation do you see between the number of visits (Variable X) and the wait times (Variable Y)? a positive correlation between Variable X and Variable Y Which of the following statements is true? A surgical operation may include one or more surgical procedures. Gail Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gail has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's RHIO Everyone in the health information department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not salaried exempt employees. In preparation for conversion to an electronic health record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data dictionary. Four people were seen in your emergency department yesterday. Which one will be coded as a poisoning?

• Josh was diagnosed with digitalis intoxication.
• Ben had an allergic reaction to a dye administered for a pyelogram

.• Bryan developed syncope after taking Contac pills with a double scotch .• Matthew had an idiosyncratic reaction between two properly administered prescription drugs. Bryan Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with feedback on specific instances when improved documentation would improve coding. Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be statutory requirements. After your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. The results of your work surprise you because the results appear to violate the Pareto principle. In your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. When this occurs, who would be expected to authorize the release of the medical information documented in this episode of care? the patient According to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is incisional. Now that the EHR has been fully implemented, you are ready to move old records to basement storage. You are ordering shelving for those old paper files. You have 18,000 records. The files average three files per filing inch. The shelf units you have selected have six shelves that will hold 34 inches per shelf. You will have to plan for a 20% expansion rate to accommodate miscellaneous paper records over the next 10 years. How many shelving units should you order? 36

You are providing an educational session to new hires at your hospital. You tell the new employees that health records may be used as evidence in court even though hearsay laws bar the use of most evidence that does not represent personal knowledge of the witness. That is because the hospital medical record was kept in the regular course of business. Your facility is engaged in a research project concerning patients newly diagnosed with type 2 diabetes. The researchers notice older patients have a longer length of stay than younger patients. They have seen a positive correlation between age and length of stay. A patient was treated for meningitis at age 3 (18 years ago). The patient is now 21. The patient's attorney is requesting information on the admission. You tell the clerk the information is available, and the patient may sign consent to release the information in the record. Employing the SOAP style of progress notes, choose the "assessment" statement from the following: Sciatica unimproved with hot pack therapy. Mary is 6 weeks post-mastectomy for carcinoma of the breast. She is admitted for chemotherapy. What is the correct sequencing of the codes? Z51.11, C50. Postage charges in the health information department have increased during the last quarter. The department director has seen metered envelopes in the mail bin that do not appear to be those used for departmental business. The best course of action for the director would be to assign responsibility for the postage meter to one employee. In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to facilities with superior performance.

A 335-bed hospital opened a new wing on June 1 of a nonleap year, increasing its bed count to 350 beds. The total bed count days for the year at the hospital was 125, Access to radiologic images has been improved through the use of which of the following? PACS The coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. This crisis manager is particularly weak in which management function? planning At your meeting with the clerical staff on the stat report concerns, one clerk suggests a possible reason for the delays is a lack of training concerning the nature of stat reports. On the cause and effect diagram, this would most appropriately be listed under personnel The Pharmacy and Therapeutics Committee has asked you to find out more about a computerized order entry system that calculates drug dosages based on patient parameters (weight, age, etc.) and even suggests the best drug given the patient's diagnosis and current treatment. The committee is asking for information on a(n) clinical decision support system. The physician has documented the final diagnoses as acute myocardial infarction, COPD, CHF, hypertension, atrial fibrillation, and status post cholecystectomy. The following conditions should be reported: I21.3, J44.9, I50.9, I11.0, I48. The transcriptionists have collected data on the number and types of problems with the dictation equipment. The best tool to display the data they collected is a Pareto chart.

Community Hospital reported an average LOS in December of 3.7 days with a standard deviation of

23. This information indicates that there was a large variation in the LOS at Community Hospital. You stop by the office to meet a friend for lunch. Looking on her desk, you see the grid above. Your friend is trying to make a decision. The electronic system at your physician practice allows for e-prescribing and the exchange of data to a centralized immunization registry, and lets your physicians report on key clinical quality measures. In all likelihood, your practice has succeeded in implementing a certified EHR When checking the census data at South Beach Women's Center, you see that just yesterday, there were four sets of triplets, five sets of twins, and eight single births. Yesterday, South Beach Women's Center had 17 deliveries You are creating an inventory of all template forms within the electronic health record. You come across an unnamed template in the OB section that includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. The document type you give to this form is postpartum record. Patient was seen today for regular hemodialysis. No problems reported, tolerated procedure well. 90935 Many of the departments in your facility create and modify forms often. A major key to forms control in this setting is giving each form or view an identifiable name, number, and revision date. During the work sampling of a file clerk's activity, it is noted that the employee is speaking on the telephone during 76 of 300 observations. How much of the employee's time is spent on the phone if the employee works 7 hours a day?

1.77 hours (Number of times on the phone/ Number of Total Observations) The state is considering the closure of the Arcadia Hospital. In reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted? percentage of occupancy When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis. The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure consistent criteria are used to evaluate the alternatives/vendors. As the information security officer at your facility, you have been asked to provide examples of technical security safeguards as required of HIPAA Security Rule. Which of the following would you provide? audit controls Sun City reported 12 cases of chronic heart disease in a population of 8,000 in 2017. In 2018, Sun City reported there were still 12 cases of chronic heart disease, but its population had decreased to 6,000. This represents an increase in the prevalence of chronic heart disease in Sun City. The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. Provide correct CPT code for the procedure. 34203 A major drug company wants to promote a fundraiser targeting patients with congestive heart failure. The drug company representative has requested a list of patients treated at your facility. As privacy and security officer, you tell them that a prior authorization is required before any PHI can be released.

A 19-year-old former patient has completed an authorization requesting all of his medical records be released to the army. The release of information clerk should send the records as requested. Diverticulitis large bowel with ascending colon abscess was the diagnosis for a patient who was admitted with abdominal pain. Right hemicolectomy with colostomy performed. K57.20, 0D1K0Z Each month, the staff of the clinic with the lowest overall waiting time is awarded a free dessert in the Gulfside Healthcare Center cafeteria. Take a look at the information listed above. The winner will be selected based on comparative aggregate data. As the director of a Health Information Technology Program, you are reviewing the workforce development forecast for electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of which governmental agency? ONC Patient was admitted from the nursing home in acute respiratory failure due to congestive heart failure. Chest x-ray also showed acute pulmonary edema. Patient was intubated and placed on mechanical ventilation for less than 24 hours and expired the day after admission. J96.00, I50.1, 5A1935Z In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post-surgery. There is no mention of a postoperative complication in the attending physician's discharge summary. Before querying the doctor, the coder will seek to confirm the infection by reviewing the lab report. The Quality Payment Program consists of four categories for the measures and activities that providers must report data for the year. Which of the following is not one of the required categories?

Physician satisfaction As a CTR, you know that staging is a system for documenting the extent or spread of cancer. Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to reduce clinical denials for medical necessity. Your facility has a team that has been working to develop a strong performance improvement model, and they have come up with the model shown above. The team asks if you see anything missing from the model. You tell them they are missing a step requiring ongoing monitoring and reassessment.