RHIA

RHIA practice questions, page 10 of 73, with answer review and explanations.

Question 46

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

  1. 24 hours.
  2. 3 days.
  3. 15 days.
  4. 60 days.

Question 47

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

  1. provide the dictated tape to his staff.
  2. request a "stat" report.
  3. write a detailed operative note in the record.
  4. request that administration hire more transcriptions.

Question 48

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?

  1. yes, within 8 hours post-surgery.
  2. no, as long as it is dictated before surgery.
  3. yes, prior to surgery.
  4. yes, within 24 hours post-surgery.

Question 49

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 patients record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

  1. quantitative record review.
  2. clinical pertinence review.
  3. concurrent record analysis.
  4. point-of-care documentation.

Question 50

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

  1. disease index.
  2. accession register.
  3. MPI.
  4. hospital census.