AHIMA AHIMA Certifications RHIA Questions & Answers

• Question 1141:

  Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, updated, and recertify the patient as appropriate. The time frame for requiring this summary is at least every

  A. week.

  B. month.

  C. 60 days.

  D. 90 days.

  Correct Answer: C

• Question 1142:

  The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

  A. documented in an incident report and filed in the patient's health record.

  B. reported as a potentially compensable event.

  C. reported to the Executive Committee.

  D. documented in both the progress notes and the discharge summary

  Correct Answer: D

• Question 1143:

  Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

  A. written within 24 hours of the patient's admission.

  B. accepted by a charge nurses only.

  C. co-signed by the attending physician within 12 hours of giving the order.

  D. accepted by persons authorized by hospital regulations and procedures.

  Correct Answer: D

• Question 1144:

  A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

  A. reliability.

  B. accessibility.

  C. legibility.

  D. completeness.

  Correct Answer: A

• Question 1145:

  Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the

  A. peer review organization.

  B. National Practitioner Data Bank.

  C. risk manager.

  D. Health Plan Employer Data and Information Set.

  Correct Answer: B

• Question 1146:

  A primary focus of screen format design in a health record computer application should be to ensure that

  A. programmers develop standard screen formats for all hospitals.

  B. the user is capturing essential data elements.

  C. paper forms are easily converted to computer forms.

  D. data fields can be randomly accessed.

  Correct Answer: B

• Question 1147:

  A quality improvement team is focusing on the unacceptable number of unsigned doctors' order sin your facility. The most effective method for increasing the timelines of signatures on orders and positively impacting the patient care process would be

  A. performing a retrospective review where all orders can be flagged at one time.

  B. holding a printed order sheet on the medical care unit at least 24 hours post discharge to give the physician time to sign.

  C. developing an open-record review process.

  D. devising a signature sheet for the attending physician to sign prospectively that will apply to all orders given during the current episode of his patient's care.

  Correct Answer: C

• Question 1148:

  In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show.

  A. missing signatures on progress notes

  B. missing discharge summaries

  C. absence of SOAP format in progress notes

  D. missing operative reports

  Correct Answer: D

• Question 1149:

  Key reports in a health record, such as history and physicals, discharge summaries, and operative reports, are generally dictated and transcribed. This recommended standard contributes most to data

  A. timeliness.

  B. accuracy.

  C. legibility.

  D. security.

  Correct Answer: C

• Question 1150:

  Which of the following is a secondary data source that be used dsto quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

  A. disease index.

  B. patient register.

  C. pediatric census sheet.

  D. procedure index.

  Correct Answer: A