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Study Guide RHIT

front 1 HIM has been recognized as an allied health profession since: A. 1910 B. 1918 C. 1928 D. 2006	back 1 C
front 2 The hospital standardization movement was inaugurated by the: A. American Health Information Management Association B. American College of Surgeons C. Record Librarians of North America D. American College of Physicians	back 2 B
front 3 Throughout the years, HIM roles have; A. Remained the same B. Broadened in scope C. Become more focused D. Diminished	back 3 B
front 4 The traditional model of HIM practice was: A. Department based B. Information based C. Electronically based D. Analytically based	back 4 A

front 5 The new model of HIM practice is: A. Information focused B. Record focused C. Department focused D. Traditionally focused	back 5 A
front 6 What evolving role oversees the process that begins at the time of documentation through billing? A. HIM director B. Health record reviewer C. Health data analyst D. Revenue cycle management	back 6 D
front 7 The organization that accredits HIM programs is: A. Joint Commission B. CAHIIM C. AHIMA D. CCHIIM	back 7 B
front 8 What evolving role assesses quality health record banking? A. Physician group consultant B. Health record reviewer C. Health data analyst D. Terminology manager	back 8 B

front 9 The primary focus of AHIMA is to: A. Ensure that health records are complete B. Implement an electronic record in hospitals C. Foster professional development of its members D. Set and implement standards	back 9 C
front 10 Active members of AHIMA include those who: A. Hold an AHIMA credential B. Are graduate members C. Are currently students in an accredited HIM program D. Are senior members	back 10 D
front 11 Which of the following functions as the legislative body of AHIMA? A. Board of Directors B. House of Delegates C. CCHIIM D. CAHIM	back 11 B
front 12 Which of the following promotes education and research? A. CCHIIM B. CAHIIM C. AHIMA D. AHIMA Foundation	back 12 C

front 13 The virtual network used by AHIMA member is: A. Certification B. Fellowship C. House of Delegates D. Communities of Practice	back 13 D
front 14 We had 324 Medicare patients last month. This statement represents which of the following: A. Information B. Data C. Content of the PHR D. Patient-specific information	back 14 B
front 15 I am a patient. My medical history including information from myself and my physicians is stored on the internet. This is an example of which of the following: A. Health record B. EHR C. PHR D. Data	back 15 C
front 16 Which of the following is an example of primary purpose of the medical record? A. Education B. Policy making C. Research D. Patient care management	back 16 D

front 17 Examples of patient care delivery usage of the medical record include which of the following uses? A. Developing of practice guidelines B. Communication between caregivers C. Reimursement for patient care D. Getting patient involved in their own care	back 17 B
front 18 Critique this statement: The PHR and EHR are synonyms. A. This is a true statement; both are controlled by the patient B. This is a false statement as the PHR is controlled by the care providers and the EHR is controlled by the patient C. This is a false statement as the PHR is controlled by the patient the EHR is controlled by the care provider D. This is a true statement; both are controlled by the health care provider	back 18 C
front 19 TRUE OR FALSE- The health record is the principal repository for data and information about the healthcare services provided to individual patients	back 19 True
front 20 TRUE OR FALSE- The lab test "hemoglobin: 14.6 gm/ 110 ml" is considered information.	back 20 False

front 21 TRUE OR FALSE- All the primary purpose of the health record are associated directly with the provision of patient care.	back 21 False
front 22 TRUE OR FALSE- Submitting health record documentation to a third party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.	back 22 False
front 23 TRUE OR FALSE- Use of the health record to study the effectiveness of a given drug is considered primary use of the health record.	back 23 False
front 24 Which of the following users of the health record is an example of an institutional user? A. Third party payer B. Accreditation organization C. Physician D. Employer	back 24 A

front 25 Which of the following users would utilize aggregate data? A. Patient care providers B. Coding and billing staff C. Law enforcement officers D. Patient care managers and support staff	back 25 D
front 26 I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization? A. Healthcare delivery B. Medical review C. Research D. Education	back 26 C
front 27 Critique this statement: A user of health records includes only care providers who document in the health record or refer to it for patient care. A. This is a true statement as defined by the IOM B. This is a false statement as the information is used for other purposes such as analysis C. This is a true statement as defined by the AHIMA D. This is a false statement as the information contained in the health record is also used for patients to document in their own health record.	back 27 B
front 28 I work for CMS; how would I use the health record? A. Make decisions on healthcare reimbursement B. Medical Research C. Issuing hospital and medical staff licenses D. Accrediting healthcare organizations	back 28 A

front 29 TRUE OR FALSE- A physical therapist is documenting in the health record is an institutional health record user.	back 29 False
front 30 TRUE OR FALSE- An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.	back 30 False
front 31 TRUE OR FALSE- CMS uses data to accredit hospitals	back 31 False
front 32 TRUE OR FALSE- A researcher uses data to determine the recommended treatment.	back 32 True

front 33 TRUE OR FALSE- Patients do not have the right to add missing information to the health record	back 33 False
front 34 A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical tool? A. Clinical decision support B. Electronic records C. Results management D. Order-entry/order management	back 34 A
front 35 I just told my physician something embarrassing about myself. I told him because I expect him to use the information for my care only. This concept is called: A. Data relevancy B. Security C. Privacy D. Confidentiality	back 35 D
front 36 Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic would be justification for not collecting this information? A. Accuracy B. Consistency C. Granularity D. Relevancy	back 36 D

front 37 It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic would be the justification for not doing this, but rather sharing information between the systems? A. Accuracy B. Consistency C. Granularity D. Relevancy	back 37 B
front 38 According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information. A. Data application B. Data collection C. Data warehousing D. Data analysis	back 38 D
front 39 A characteristic of data whose values are defined at the appropriate level of detail A. Data granularity B. Security C. Privacy D. Data comprehensive E. Data relevancy	back 39 A
front 40 A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records A. Data granularity B. Security C. Privacy D. Data comprehensive E. Data relevancy	back 40 B

front 41 A characteristic of data where the data are useful A. Data granularity B. Security C. Privacy D. Data comprehensive E. Data relevancy	back 41 E
front 42 An individual's right to control access to his or her personal information A. Data granularity B. Security C. Privacy D. Data comprehensive E. Data relevancy	back 42 C
front 43 A characteristics of data that includes every required data element A. Data granularity B. Security C. Privacy D. Data comprehensive E. Data relevancy	back 43 D
front 44 Which two major types of data are contained in the health record? A. Nursing and Physician B. Administrative and clinical C. Demographic and financial D. Surgical and medical	back 44 B

front 45 Which of the following terms refers to state county regulations that healthcare facilities must meet to be permitted to provide care? A. Accreditation B. Bylaws C. Certification D. Licensure	back 45 D
front 46 Which of the following should not be found in a medical history? A. Chief complaint B. Vital signs C. Present illness D. Review systems	back 46 B
front 47 An attending physicians requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report? A. Consultation B. Progress note C. Operative report D. Discharge summary	back 47 A
front 48 Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? A. Flow record B. Vital signs record C. Care plan D. Surgical note	back 48 C

front 49 Written or spoken permission to proceed with care is classified as: A. Expressed consent B. Acknowledgement C. Advance directive D. Implied consent	back 49 A
front 50 Which of the following reports provides information on tissue removing during surgery? A. Operative report B. Laboratory report C. Pathology report D. Anesthesia report	back 50 C
front 51 Sleeping patterns, head chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following record? A. Obstetric B. Newborn C. Surgical D.Emergency	back 51 B
front 52 Which of the following is not considered patient demographic information? A. Patient's date of birth B. Name of next kin C. Type of admission D. Admitting diagnosis	back 52 D

front 53 Which of the following administrative documents names the patient's choice of legal representative for healthcare purposes? A. Advance Directive B. Patient Bill of Rights C. Notice of Privacy Practices D. Authorization for Release of Information	back 53 A
front 54 1. Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient? A. Ambulatory care B. Emergency care C. Long-term care D. Rehabilitation care	back 54 B
front 55 Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record? A. Ambulatory care B. Emergency care C. Long-term care D. Rehabilitation care	back 55 A
front 56 The ambulatory surgery record contains information most similar to: A. Physician's office record B. Emergency care records C. Hospital operative record D. Hospital obstetric records	back 56 C

front 57 Which standardization tool is used to assess Medicare-certified rehabilitation facilities? A. Outcomes and Assessment Information Set (OASIS) B. Resident assessment protocol (RAP) C. Patient assessment instrument (PAI) D. Minimum Data Set (MDS)	back 57 C
front 58 Interdisciplinary care plans are an important part of which type of health record? A. Emergency department B. Ambulance C. Hospice care D. Ambulatory care	back 58 C
front 59 Portions of a treatment record may be maintained in a patient's home in which two types of settings? A. Hospice and behavioral health B. Home health and end-stage renal disease C. Obstetric and gynecologic care D. Rehabilitation and correctional care	back 59 B
front 60 A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record? A. Rehabilitation care B. Ambulatory care C. Behavioral health D. Personal health	back 60 C

front 61 Paper records may require thinning in which two settings? A. Home health and hospice B. Rehabilitation and end-stage renal disease C. Ambulatory care and behavioral health D. Long-term care and correctional services	back 61 D
front 62 A growth and development record may be found in what type of record? A. Rehabilitation care B. Pediatric C. Behavioral health D. Obstetric	back 62 B
front 63 The document that indicates current and past medical condition is: A. MDS B. RAPs C. Problem list D. PAI	back 63 C
front 64 Which of the following is an accrediting organization? A. State regulating services B. American Health Information Management Association C. DNV (De Norske Veritas) D. Centers for Medicare and Medicaid Services	back 64 C

front 65 An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation under its guidelines do not need to: A. Meet licensure standards B. Undergo Medicare certification surveys C. Undergo accreditation survey's D. Meet Medicare certification standards	back 65 B
front 66 Which group focuses on accreditation of managed care and preferred provider organizations? A. Accreditation Association for Ambulatory Healthcare B. National Committee for Quality Assurance C. Commission on Accreditation of Healthcare Organizations D. Joint Commission on Accreditation of Healthcare Organization	back 66 B
front 67 Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patient record? A. Facility rules and regulations B. Accreditation standards C. Licensure standards D. Conditions of Participation	back 67 A
front 68 Which of the following groups has instituted a health record-prohibited abbreviation list? A. National Committee for Quality Assurance B. Joint Commission on Accreditation of Healthcare Organization C. American Osteopathic Association D. Centers of Medicare and Medicaid Service	back 68 B

front 69 Which type of health record includes both paper and computerized components? A. Hybrid B. Electronic C. Problem-oriented D. Source-oriented	back 69 A
front 70 Which of the following is a disadvantage of an EHR over a paper based record? A. Allows customization to user needs B. Permits multiple users at the same time C. Enables duplicate copies to be made easily D.Requires privacy and security measures	back 70 D
front 71 In an integrated health record, documentation by health professionals is organized: A. In sections by type of professional B. In sections by problem number C. Intermixed in data sequence D. Depends on facility policy	back 71 C
front 72 The patient indicates that her pain is worse, In which part of SOAP note would this information be recorded? A. Subjective B.Objective C. Assessment D. Plan	back 72 A

front 73 Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state? A. Database management B. Image processing C. Text processing D. Vocabulary standards	back 73 B
front 74 Which of the following is true of paper-based records? A. They are susceptible	back 74 no data