AHIMA AHIMA Certifications RHIA Questions & Answers

• Question 1211:

  Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

  A. chief of staff.

  B. attending physician.

  C. HIM director.

  D. risk manager.

  Correct Answer: B

• Question 1212:

  The performance of ongoing record reviews is an important tool is ensuring data quality through accurate health records. These reviews evaluate

  A. quality of care through the use of pre-established criteria.

  B. adverse effects and contraindications of drugs utilized during hospitalization.

  C. potentially compensable events.

  D. completeness, adequacy, and quality of documentation.

  Correct Answer: D

• Question 1213:

  Discharge summary documentation must include

  A. a detailed history of the patient.

  B. a note from social services or discharge planning.

  C. significant findings during hospitalization.

  D. correct codes for significant procedures

  Correct Answer: C

• Question 1214:

  The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar rmeasures might be utilized to govern the use of

  A. fingerprint signatures.

  B. voice recognition systems.

  C. expert systems.

  D. electronic signatures.

  Correct Answer: D

• Question 1215:

  The minimum length of time for retaining original medical records is primarily governed by

  A. Joint Commission.

  B. medical staff.

  C. state law.

  D. readmission rates.

  Correct Answer: C

• Question 1216:

  As a new CTR, you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility's

  A. disease index.

  B. number control index.

  C. physicians' index.

  D. patient index.

  Correct Answer: A

• Question 1217:

  Joint Comission requires the attending physician to countersign health record documentation that is entered by

  A. interns or medical students.

  B. midwives.

  C. consulting physicians.

  D. physician partners.

  Correct Answer: A

• Question 1218:

  As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an HandP performed in her office a week before admission. You tell Dr. Crossman.

  A. a new HandP is required for every inpatient admissions.

  B. that you apologize for not noticing the HandP she provided.

  C. the HandP copy is acceptable as long as she documents any interval changes.

  D. Joint Commission standards do not allow copies of any kind in the original record.

  Correct Answer: C

• Question 1219:

  As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

  A. prenatal record.

  B. labor and delivery record.

  C. postpartum record.

  D. discharge summary.

  Correct Answer: A

• Question 1220:

  Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

  A. it is too easy to delegate use of computer passwords.

  B. evidence cannot be provided that the physician actually reviewed and approved each report.

  C. electronic signatures are not acceptable in every state.

  D. tampering too often occurs with this method of authentication.

  Correct Answer: B