AHIMA AHIMA Certifications RHIA Questions & Answers

• Question 1161:

  Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

  A. peer review.

  B. quantitative review.

  C. qualitative review.

  D. legal analysis.

  Correct Answer: C

• Question 1162:

  As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult

  A. Consolidated Manual for Hospitals

  B. Federal Register

  C. Policy and Procedure Manual

  D. Hospital Bylaws, Rules, and Regulations

  Correct Answer: D

• Question 1163:

  As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

  A. DEEDS.

  B. UHDDS.

  C. MDS.

  D. ORYX.

  Correct Answer: A

• Question 1164:

  Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a

  A. data warehouse.

  B. regional health information organization.

  C. continuum of care.

  D. data retrieval portal group.

  Correct Answer: B

• Question 1165:

  Which method of identification of authorship or authentication of entries would be in appropriate to use in a patient's health record?

  A. written signature of the provider of care

  B. identifiable initials of a nurse writing a nursing note

  C. a unique identification code entered by the person making the report

  D. delegated use of computer key by radiology secretary

  Correct Answer: D

• Question 1166:

  Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

  A. chronic pain management.

  B. palliative care.

  C. brain injury management.

  D. vocational evaluation.

  Correct Answer: B

• Question 1167:

  In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

  A. integrated progress notes.

  B. interdisciplinary treatment plans.

  C. source-oriented records.

  D. SOAP notes.

  Correct Answer: A

• Question 1168:

  In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

  A. generic screens used by record abstractors.

  B. Disease index.

  C. R-ADT system.

  D. Indicator monitoring program.

  Correct Answer: C

• Question 1169:

  The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely to include checking for documentation regarding

  A. the presence or absence of such items as preoperative and postoperative diagnosis description of findings, and specimens removed.

  B. whether a postoperative infection occurred and how it was treated.

  C. the quality of follow-up care.

  D. whether the severity of illness and/or intensity of service warranted acute level care.

  Correct Answer: A

• Question 1170:

  The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

  A. tissue examination done by the pathologist

  B. impressions of a cardiologist asked to determine whether patient is a good surgical risk

  C. interpretation of a radiologic study

  D. technical interpretation of electrocardiogram

  Correct Answer: B