AHIMA AHIMA Certifications RHIA Questions & Answers

• Question 1131:

  As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document

  A. objective symptoms observed by the physician.

  B. past and current activities, such as smoking and drinking habits.

  C. a chronological description of patient's present condition from time of onset to present.

  D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.

  Correct Answer: D

• Question 1132:

  In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

  A. standing orders.

  B. telephone orders.

  C. stop orders.

  D. discharge order.

  Correct Answer: D

• Question 1133:

  One record documentation requirement shared by BOTH ascute care and emergency departments is

  A. patient's condition on discharge.

  B. time and means of arrival.

  C. advance directive.

  D. problem list.

  Correct Answer: A

• Question 1134:

  Documentation found in acute care health records should include core measure quality indications required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for pneumonia patients is

  A. beta blocker at discharge.

  B. blood culture before first antibiotic received.

  C. early administration of aspirin.

  D. discharged on antithrombotic.

  Correct Answer: B

• Question 1135:

  For inpatients, the first data item collected of a clinical nature is usually

  A. principal diagnosis.

  B. expected payer.

  C. admitting diagnosis.

  D. review of systems.

  Correct Answer: C

• Question 1136:

  In an acute care facility, the responsibility for education physicians and other health care providers regarding proper documentation policies belongs to the

  A. information security manager.

  B. clinical data specialist.

  C. health information manager.

  D. risk manager.

  Correct Answer: C

• Question 1137:

  Still referring to the information in the table in question number 88, which area represents the greatest area of concern for Springfield Hospital's compliance with Joint Commission standards?

  A. incomplete records.

  B. delinquent records.

  C. delinquent HandP.

  D. delinquent operative reports.

  Correct Answer: D

• Question 1138:

  Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital.

  A. 55%.

  B. 32%.

  C. 33%.

  D. 54%.

  Correct Answer: B

• Question 1139:

  A quarterly review reveals the following data for Springfield Hospital:

  

  What is the percentage of incomplete records during this quarter?

  A. 55%

  B. 54%

  C. 33%

  D. 32%

  Correct Answer: A

• Question 1140:

  You want to review the one document in your facility that will spell out the documentation requirements for patient records; designate the time frame for completion by the active medical staff; and indicate the penalties for failure to comply with these record standards. Your best resource will be

  A. medical staff bylaws.

  B. quality management plan.

  C. Joint Commission accreditation manual.

  D. medical staff rules and regulations.

  Correct Answer: D