AHIMA AHIMA Certifications RHIA Questions & Answers

• Question 1181:

  You notice on the admission HandP that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

  A. interval summary.

  B. consultation report.

  C. advance directive.

  D. interdisciplinary care plan.

  Correct Answer: B

• Question 1182:

  As the chair of a Forms Review Committee, you need to track the origin of data in a particular field and the security levels applicable to that field. Your best source for this information would be the

  A. facility's data dictionary.

  B. MDS.

  C. Glossary of Health Care Terms.

  D. UHDDS.

  Correct Answer: A

• Question 1183:

  In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each resident as defined in the

  A. UHDDS.

  B. MDS.

  C. Uniform Clinical Data Set.

  D. Uniform Ambulatory Core Data.

  Correct Answer: B

• Question 1184:

  Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

  A. sciatica unimproved with hot pack therapy

  B. patient moving about very cautiously, appears to be in pain

  C. adjust pain medication; begin physical therapy tomorrow

  D. patient states low back pain is as severe as it was on admission

  Correct Answer: D

• Question 1185:

  According to the following table, the most serious record delinquency problem occurred in A. April

  

  B. May.

  C. June

  D. cannot determine from this data.

  Correct Answer: A

• Question 1186:

  Under which of the following conditions can an original patient health record by physically removed from the hospital?

  A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital

  B. when the directory of health records is acting in response to a subpoena duces tecum and takes the health record to court

  C. when the patient is discharged by the physician and at the time of discharge is transported to a longterm care facility with his health record

  D. when the record is taken to a physician's private office for a follow-up patient visit postdischarge

  Correct Answer: B

• Question 1187:

  In creating a new form or computer view, the designer should be most driven by

  A. QIO standards.

  B. medical staff bylaws.

  C. needs of the users.

  D. flow of data on the page or screen.

  Correct Answer: C

• Question 1188:

  A data item to include on a qualitative review checklist of infant and children inpatient health records which need not be included on adult records would be

  A. chief complaint.

  B. condition on discharge.

  C. time and means of arrival.

  D. growth and development record.

  Correct Answer: D

• Question 1189:

  For each report of care rendered to a patient, the health record entry should include the date plus the provider's name and

  A. department.

  B. discipline.

  C. initials.

  D. supervising physician.

  Correct Answer: B

• Question 1190:

  A key data item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record is the

  A. physical findings.

  B. lab and diagnostic test results.

  C. time and means of arrival.

  D. instructions for follow-up care.

  Correct Answer: C