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Domain 1 Health Data Management
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1

A critical early step in designing an EHR is to develop a(n)___ in which the characteristics of each data element are defined.

A. Accreditation manual
B. Core content
C. Continuity of care record
D. Data dictionary

D

2

Once a hospital discharge abstract system were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop:

A. Data sets
B. Data elements
C. Electronic data interchange
D. Bills of mortality

A

3

In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to:

A. Provide uniform data definitions
B. Guide efforts toward computerization
C. Determine statistical formulas
D. Provide a research database

A

4

A health information technician is responsible for designing a data collection form to collect data on patients in an acute care hospital. The first resource that he or she should us is:

A. UHDDS
B. UACDS
C. MDS
D. ORYX

A

5

Which of the following is not a characteristic of the common healthcare data set such as UHDDS and UACDS?

A. They define minimum data elements to be collected
B. They provide a complete and exhaustive list of data elements that must be collected
C. They provide a framework for data collection to which an individual facility can add data items
D. The federal government recommends, but does not mandate, implementation of most of the data sets

B

6

A corporation is evaluating several health plans for its benefits package. The data set that provides the comparison information about health plan performance is:

A. ORYX
B. HEDIS
C. UHDDS
D. MDS

B

7

The name of the government advisory group that makes proposals for improvement of basic data sets for health records and computer database is:

A. Centers for Medicare and Medicaid Services
B. Johns Hopkins University
C. American National Standards Institute
D. National Committee on Vital and Health Statistics

D

8

The primary purpose of a minimum data set in healthcare is to:

A. Recommend common data elements to collected in health records
B. Mandate all data that must be contained in a health record
C. Define reportable data for federally funded programs
D. Standardize medical vocabulary

A

9

The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the:

A. Ambulatory Care Data Set
B. Uniform Hospital Discharge Data Set
C. Minimum Data Set for Long-Term Care
D. Health Plan Employer Data and Information Set

B

10

Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for:

A. Performance improvement programs
B. Billing and claims data processing
C. Developing hospital discharge abstracting system
D. Developing individual care plans for residents

A

11

The focus of out patient data collection in the UACDS is on:

A. Reason for admission
B. Reason for encounter
C. Discharge diagnosis
D. Activities of daily living

B

12

In long-term care, the resident's care plan is based on data collected in the:

A. UHDDS
B. OASIS
C. MDS
D. HEDIS

C

13

Reimbursement for home health services is dependent on data collection from:

A. HEDIS
B. UHDDS
C. OASIS
D. MDS

C

14

Each of the three dimensions (personal, provider, and community) of information defined by the National Health Information Network (NHIN) contains specific recommendations for:

A. Government regulations
B. Core data elements
C. Privacy controls
D. Technology requirements

B

15

A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is:

A. Continuity of Care Record
B. Minimum Data Set
C. Ambulatory Care Data Set
D. Uniform Hospital Discharge Data Set

A

16

The home health prospective payment system uses the _____ data set for patient assessments

A. HEDIS
B. OASIS
C. MDS
D. UHDDS

B

17

The government agency most closely involved in the development of healthcare data sets and information standards is:

A. Centers for Medicare and Medicaid Services
B. Department of Health and Human Services
C. John Hopkins University
D. National Center for Health Statistics

D

18

The data set designed to organize data for public release about the outcomes of care is:

A. UHDDS
B. DEEDS
C. MDS
D. HEDIS

D

19

OASIS data are used to assess the _____ of home health service.

A. Outcome
B. Financial performance
C. Utilization
D. Core measure

A

20

Which of the following includes patient-identifiable information?

A. MEDLINE
B. Clinical trials database
C. Master patient/ population index
D. UMLS

C

21

A notation for a diabetic patient in a physicians progress notes reads; "Occasionally gets hungry. No insulin reactions. Says she follows her diabetic diet." In which part of a POMR progress note would this be written?

A. Subjective
B. Objective
C. Assessment
D. Plan

A

22

A notation for a diabetic patient in a physicians progress note reads: "FBS 110 mg%, urine sugar, no acetone," In which part of POMR progress note would this be written?

A. Subjective
B. Objective
C. Assessment
D. Plan

B

23

A notation for hypersensitive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mg once daily. Return visit in 2 week." In which part of a POMR progress note would this be written?

A. Subjective
B. Objective
C. Assessment
D. Plan

D

24

A notation for a hypersensitive patient in ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this be written?

A. Subjective
B. Objective
C. Assessment
D. Plan

C

25

A specific set of terms that may be used in an EHR is referred to as a:

A. Classification
B. Nomenclature
C. Nominal data
D. Controlled vocabulary

D

26

Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services?

A. Current Procedural Terminology
B. Healthcare Common Procedure Coding System
C. International Classification of Diseases, Ninth Revision, Clinical Modification
D. International Classification of Disease for Oncology, Third Edition

B

27

Which of the following is a classification system specifically for coding histology, topography, and behavior of neoplasms?

A. Current Procedural Terminology
B. Healthcare Common Procedure Coding Systems
C. International Classification of Diseases for Oncology, Third Edition
D. Systematized Nomenclature of Medicine Clinical Terminology

C

28

Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?

A Current Procedural Terminology
B. Healthcare Common Procedure Coding System
C. International Classification of Diseases, Ninth Revision, Clinical Modification
D. Systematized Nomenclature of Medicine Clinical Terminology

D

29

Which of the following is a system for classifying morbidity and mortality information for statistical purposes?

A. Current Procedural Terminology
B. Diagnostic and Statistical Manual of Mental Disorders, Forth Revision
C. Healthcare Common Procedure Coding System
D. International Classification of Diseases, Ninth Revision, Clinical Modification

D

30

Which of the following is not a knowledge source for users of the Unified Medical Language System?

A. Concept table
B. Semantic network
C. Metathesaurus
D. Specialist lexicon

A

31

Nosology can be defined as the branch of medical science that deals with:

A. Cosmetic surgery
B. Hospital-acquired infections
C. Nursing diagnoses
D. Classification systems

D

32

Which of the following classifications is used exclusively for classifying cases of malignant disease?

A. CPT
B. HCPCS
C. ICD-9-CM
D. ICD-0-3

D

33

Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?

A. CPT
B. HCPCS
C. ICD-9-CM
D. SNOMED CT

D

34

WHich of the following provides a set of codes used for collecting data about substance abuse and the mental health disorders?

A. CPT
B. DSM-IV-TR
C. HCPCS
D. SNOMED CT

B

35

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?

A. Data compliance
B. Data relevancy
C. Data currency
D. Data precision

C

36

Mrs. Smith's admitting data indicates that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?

A. Data compliance
B. Data consistency
C. Data accessibility
D. Data comprehension

B

37

The term used to describe expected data value is:

A. Data definition
B. Data currency
C. Data precision
D. Data relevancy

C

38

The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as a carcinoma on the discharge summary. This is an example of a problem with:

A. Data granularity
B. Data consistency
C. Data precision
D. Data relevance

B

39

Which of the following is a primary weakness of the paper-based health record?

A. Difficulty to provide availability to a number of providers at the same time
B. Poor communication tool
C. Difficulty in documenting healthcare processes
D. Lack of available reources

A

40

Which of the following elements is not a component of most patient records?

A. Patient Identification
B. Clinical history
C. Invoice for service
D. Test results

C

41

Which of the following is not a characteristic of high-quality healthcare data?

A. Data relevancy
B. Data currency
C. Data consistency
D. Data accountability

D

42

Which of the following represents an example of data granularity?

A. A progress note recorded at or near the time of the observation
B. An acceptable range of values defined for clinical characteristic
C. A numerical measurement carried out to the appropriate decimal place
D. A health record that includes all of the required components

C

43

Which of the following is a primary purpose of the health record?

A. Document patient care delivery
B. Regulation of healthcare facilities
C. Aid in education of nurses and physicians
D. Data reliable

A

44

Which of the following best describes data accuracy?

A. Data are correct
B. Data are easy to obtain
C. Data include all required elements
D. Data are reliable

A

45

Which of the following best describes data comprehensiveness?

A. Data are correct
B. Data are easy to obtain
C. Data include all required elements
D. Data are reliable

C

46

Which of the following best describes data accessibility?

A. Data are correct
B. Data are easy to obtain
C. Data include all required elements
D. Data are reliable

B

47

In which department or unit is the health record number typically assigned?

A. HIM
B. Patient registration
C. Nursing
D. Billing

B

48

Identify where the following information would be found in the acute-care record; "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion."

A. Anesthesia report
B. Physicians progress notes
C. Operative report
D. Recovery room record

C

49

Identify where the following information would be found in the acute-care record: "CBC, WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MVC 93."

A. Medical laboratory report
B. Pathology report
C. Physical Examination
D. Physician orders

A

50

Identify where the following information would be found in the acute-care record; "PA and Lateral Chest: The lungs are clear. the heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine."

A. Medical Laboratory report
B. Physical Examination
C. Physician progress note
D. Radiography report

D

51

The attending physician is responsible for which of the following types of acute-care documentation?

A. Consultation report
B. Discharge summary
C. laboratory report
D. Pathology report

B

52

A nurse is responsible for which of the following types of acute-care documentation?

A. Operative report
B. Medication record
C. Radiology report
D. Therapy assessment

B

53

Which of the following is an example of clinical data?

A. Admitting diagnosis
B. Data and time of admission
C. Insurance information
D. Health record number

A

54

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of speciality record?

A. Home health
B. Behavioral health
C. End-stage renal disease
D. Outpatient care

A

55

The following is documented in a acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear?

A. History
B. Pathology report
C. Physical Examination
D. Operative reprot

C

56

The following is documented in acute-care record; "Microscopice: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear?

A. History
B. Pathology report
C. Physical Examination
D. Operative report

B

57

The following is documented in an acute-care record: "Admit ti 3C. Diet: NPO Meds: Compazine 10mg IV Q 6 PRN." In which of the following would this documentation appear?

A. Physician order
B. History
C. Physical Examination
D. Progress notes

A

58

The following is documented in an acute-care record: "The patient was places in the supine position and prepped and draped in the usual manner. Following induction of anesthesia, an incision was made." In which of the following would this documentation appear?

A. Anesthesia record
B. Discharge summary
C. Operative report
D. Progress notes

C

59

The following is documented in an acute-care record: "Gluc 97, BUN 12, K 40, and PHOS 3.0." In which of the following would this documentation appear?

A. Anesthesia report
B. Clinical Laboratory report
C. Respiratory report
D. Radiology report

B

60

The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear?

A. Admission note
B. Clinical Laboratory
C. Newborn record
D. Physician order

C

61

The following is documented in an acute-care record; "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear?

A. Admission order
B. Clinical laboratory report
C. ECG report
D. Radiology report

C

62

The following is documented in an acute-care record; "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following documentation would this appear?

A. Admission note
B. Consultation report
C. Discharge summary
D. Nursing progress notes

B

63

The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral, Case manager to meet with patient and family." In which of the following documentation would this appear?

A. Admission note
B. Nursing note
C. Physician progress note
D. Social service note

D

64

Which of the following is not usually a part of quantitative analysis review?

A. Checking that all forms contain the patient's name and health record number
B. Checking that all forms and reports are present
C. Check that every word in the record is spelled correctly
D. Checking that all reports requiring authentication have signatures

C

65

Which of the following materials is not documented in an emergency care record?

A. Patient's instructions at discharge
B. Time and means of the patient's arrival
C. Patient's complete medical history
D. Emergency care administered before arrival at the facility

C

66

Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure?

A. Anesthesia report
B. Laboratory report
C. Operative report
D. Pathology report

D

67

Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in which of the following records?

A. Emergency
B. Newborn
C. Obstetric
D. Surgical

B

68

In a problem-oriented medical record, problems are organized:

A. In alphabetical order
B. In numeric order
C. In alphabetical order by body system
D. By date of onset

B

69

Which of the following best describes an integrated health record format?

A. Each section of the record is maintained by the patient care department that provided the care
B. Integrated health records are intended to be used in ambulatory settings
C. Documentation is integrated and arranged in alphabetical order by documentation type
D. Documentation from various sources are integrated and arranged in strict chronological order

D

70

Which of the following represents documentation of the patient's current and past health status?

A. Physical exam
B. Medical History
C. Physician orders
D. Patient consult

B

71

Which of the following contains the physician's findings based on an examination of the patient?

A. Physical exam
B. Discharge summary
C. Medical History
D. Patient information

A

72

What is the function of a consultation report?

A. Provides a chronological summary of the patient's medical history and illness
B. Documents opinions about the patient's conditions from the perspective of the physician not previously involved in the patient's care
C. Concisely summarizes the patient's treatment and stay in the hospital
D. Documents the physician's instructions to other parties involved in providing care to a patient

B

73

What is the function of physician's orders?

A. Provide a chronological summary of the patient's illness and treatment
B. Document the patient's current and past health status
C. Document the physician's instructions to other parties involved in providing care to a patient
D. Document the provider's instructions for follow-up care given to the patient or patient's caregiver

C

74

Which type of patient care record includes documentation of a family bereavement period?

A. Hospice record
B. Home health record
C. Long-term care record
D. Ambulatory record

A

75

Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ___ review?

A. Quantitative
B. Qualitative
C. Statistical
D. Outcomes

A

76

Which of the following is a secondary purpose of the health record?

A. Support for provider reimbursement
B. Support for patient self-management activities
C. Support for research
D. Support for patient care delivery

C

77

Use of health record by a clinician to facilitate quality patient care is considered:

A. A primary purpose of the health record
B. Patient care support
C. A secondary purpose of the health record
D. Policy making and support

A

78

Use of the health record to monitor bioterrorism activity is considered a:

A. Primary purpose of the health record
B. Secondary purpose of the health record
C. Patient use of the health record
D. Healthcare licensing agency function

B

79

In designing an electronic health record, one of the best resources to use to define the structure and content and standardize data definitions are standards promulgated by the:

A. Centers for Medicare and Medicaid Services
B. American Society for Testing and Measurement
C. Joint Commission
D. National Center for Health Statistics

B

80

The ____ mandated the development of standards for electronic medical records.

A. Medicare and Medicaid legislation of 1965
B. Prospective Payment Act of 1983
C. Health Insurance Portability and Accountability Act (HIPAA) of 1996
D. Balanced Budget Act of 1997

C

81

Messaging standards for electronic data interchange in healthcare have been developed by:

A. HL7
B. HEDIS
C. The Joint Commission
D. CMS

A

82

A statement or guideline that directs decision making or behavior is called a:

A. Directive
B. Procedure
C. Policy
D. Process

C

83

Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2?

A. Current Procedural Terminology (CPT)
B. International Classification of Diseases, Tenth Revision, Clinical Modicifcation
C. International Classification of Diseases, Tenth Revision  (ICD-10)
D. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

D

84

Which organization originally publishes ICD and it's revisions?

A. American Medical Association
B. Centers for Disease Control
C. Untied States federal government
D. World Health Organization

D

85

Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?

A. Centers for Disease Control
B. Centers for Medicare and Medicaid Services
C. National Center for Health Statistics
D. World Health Organization

B

86

At which level of the classification systems are the most specific ICD-9-CM codes found?

A. Category level
B. Section level
C. Subcategory level
D. Subclassification level

D

87

What are five digit ICD-9-CM diagnosis codes referred to as?

A. Category codes
B. Section codes
C. Subcategory codes
D. Subclassification codes

D

88

What are four-digit ICD-9-CM diagnosis codes referred to as?

A. Category codes
B. Sections codes
C. Subcategory codes
D. Subclassification codes

C

89

Which of the following ICD-9-CM codes are always alphanumeric?

A. Category codes
B. Procedure codes
C. Subcategory codes
D. External causes of injury and poisoning

D

90

Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect?

A. Category codes
B. E codes
C. Subcategory codes
D. V codes

B

91

Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?

A. Volume 1
B. Volume 2
C. Volume 3
D. Volume 4

C

92

Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals?

A. Current Procedural Terminology
B. Diagnostic and Statistical Manual of Mental Disorders, Forth Revision
C. Healthcare Common Procedure Coding System
D. International Classification of Diseases, Ninth Revision, Clinical Modification

A

93

Which of the following is used to report healthcare supplies, products, and services provided to patients by healthcare professionals?

A. CPT
B. HCPCS
C. ICD-9-CM
D. SNOMED CT

B

94

Which of the following is a standard terminology used to code medical procedures and services?

A. CPT
B. HCPCS
C. ICD-9-CM
D. SNOMED CT

A

95

Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures?

A. Reliability
B. Validity
C. Completeness
D. Timeliness

C

96

A patient is admitted to the hospital with acute lower abdominal pain. The principal dx is acute appendicitis. The patient also has a dx of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a co-morbid condition?

A. Acute appendicitis
B. Appendectomy
C. Diabetes
D. Wound infection

C

97

A Medicare patient had two physician office visits, underwent hospital radiology examinations, clinical lab tests, and received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system?

A. Clinical Lab tests
B. Physician office visit
C. Radiology examinations
D. Take-home surgical dressing

C

98

Which payer does the hospital proportionately receive the least amount of payment
Payer, Chrg, Pymt, Adj, Chrg, Pymt, Adj
Medicaid 350th 75th 275th 18% 6% 36%
Medicare 750th 495th 255th 39% 42% 33%
TRICARE 150th 50th 100th 7% 4% 13%

A. Medicare
B. Medicaid
C. Tricare
D. BCBS

B

99

What term is used for retrospective cash payments paid by the patient for services rendered by a provider?

A. Fee-for-service
B. Deductible
C. Retrospective
D. Prospective

A

100

Which of the following is the condition established after the study to be the reason for hospitalization?

A. Case mix
B. Complication
C. Comorbidity
D. Principal diagnosis

D

101

In which of the following payment systems is the amount of payment determined before the service is delivered?

A. Fee-for-service
B. Per diem
C. Prospective
D. Retrospective

C

102

Which of the following is a prospective payment system implementation for payment of inpatient services?

A. APC
B. DRG
C. OPPS
D. RBRVS

B

103

In the Inpatient Prospective Payment System, assignment to a DRG begins with the:

A. Principal Diagnosis
B. Primary Diagnosis
C. Secondary Diagnosis
D. Surgical procedure

A

104

Which of the following types of hospitals are excluded from Medicare inpatient perspective payment systems?

A. Children's
B. Rural
C. State supported
D. Tertiary

A

105

Diagnosis-related group are organized into:

A. Case-mix classifications
B. Geographic practice cost indices
C. Major diagnostic categories
D. Resource-based relative values

C

106

MS-DRG may be split into a maximum of ____ payment tiers based on severity as determined by the prescence of a major complication/comorbidity, a CC; or no CC.

A. Two
B. Three
C. Four
D. Five

B

107

The purpose of the present on admission (POA) indicator is to:

A. Differentiate between conditions present on admission and conditions that develop during an inpatient admission
B. Track principal diagnoses
C. Distinguish between principal and primary diagnoses
D. Determine principal diagnosis

A

108

The present on admission (POA) indicator is a requirement for

A. Inpatient Medicare claims submitted by all hospitals
B. Inpatient Medicare and Medicaid claims submitted by hospitals
C. Medicare claims submitted by all entities
D. Inpatient skilled nursing facility Medicare claims

A

109

Which of the following is associated with the Medicare fee schedule

A. APC's
B. MS-DRGs
C. RBRVS
D. RUG-III

C

110

SNFs complete MDS assessments:

A. On admission and once every 14 days
B. Once every 30 days up to 180 days
C. According to designated reassessment points
D. Depending on the diagnosis of patient

C