RHIA

RHIA practice questions, page 11 of 73, with answer review and explanations.

Question 51

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

  1. objective survey of body systems.
  2. chief complaint.
  3. family history.
  4. subjective review of systems.

Question 52

During a retrospective review of Rose Hunters 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?

  1. utilization review.
  2. quantitative review.
  3. legal review.
  4. qualitative review.

Question 53

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

  1. missing discharge summary
  2. needs for physician authentication of two verbal orders
  3. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist
  4. x-ray report charted on the wrong record

Question 54

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?

  1. tissue examination done by the pathologist
  2. impressions of a cardiologist asked to determine whether patient is a good surgical risk
  3. interpretation of a radiologic study
  4. technical interpretation of electrocardiogram

Question 55

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

  1. the presence or absence of such items as preoperative and postoperative diagnosis description of findings, and specimens removed.
  2. whether a postoperative infection occurred and how it was treated.
  3. the quality of follow-up care.
  4. whether the severity of illness and/or intensity of service warranted acute level care.