AHIMA AHIMA Certifications RHIA Questions & Answers

• Question 1171:

  Which of the following is least likely to be identified by the deficiency analysis clerk?

  A. missing discharge summary

  B. needs for physician authentication of two verbal orders

  C. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist

  D. x-ray report charted on the wrong record

  Correct Answer: C

• Question 1172:

  During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was missed dose of insulin. What type of review is this clerk performing?

  A. utilization review.

  B. quantitative review.

  C. legal review.

  D. qualitative review.

  Correct Answer: D

• Question 1173:

  In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the

  A. objective survey of body systems.

  B. chief complaint.

  C. family history.

  D. subjective review of systems.

  Correct Answer: A

• Question 1174:

  An example of a primary data source for health care statistics other than the patient health record is the

  A. disease index.

  B. accession register.

  C. MPI.

  D. hospital census.

  Correct Answer: D

• Question 1175:

  The old practice of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

  A. quantitative record review.

  B. clinical pertinence review.

  C. concurrent record analysis.

  D. point-of-care documentation.

  Correct Answer: D

• Question 1176:

  Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

  A. yes, within 8 hours post-surgery.

  B. no, as long as it is dictated before surgery.

  C. yes, prior to surgery.

  D. yes, within 24 hours post-surgery.

  Correct Answer: C

• Question 1177:

  A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should

  A. provide the dictated tape to his staff.

  B. request a "stat" report.

  C. write a detailed operative note in the record.

  D. request that administration hire more transcriptions.

  Correct Answer: C

• Question 1178:

  A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

  A. 24 hours.

  B. 3 days.

  C. 15 days.

  D. 60 days.

  Correct Answer: B

• Question 1179:

  You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report be should be set at

  A. 12 hours after admission.

  B. 24 hours after admission.

  C. 12 hours after admission or prior to surgery.

  D. 24 hours after admission or prior to surgery.

  Correct Answer: D

• Question 1180:

  An example of objective entry in the health record supplied by a health care practitioner is the

  A. past medical history.

  B. physical assessment.

  C. chief complaint.

  D. review of systems.

  Correct Answer: B