RHIA

RHIA practice questions, page 16 of 73, with answer review and explanations.

Question 76

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show.

  1. missing signatures on progress notes
  2. missing discharge summaries
  3. absence of SOAP format in progress notes
  4. missing operative reports

Question 77

A primary focus of screen format design in a health record computer application should be to ensure that

  1. programmers develop standard screen formats for all hospitals.
  2. the user is capturing essential data elements.
  3. paper forms are easily converted to computer forms.
  4. data fields can be randomly accessed.

Question 78

A quality improvement team is focusing on the unacceptable number of unsigned doctors order sin your facility. The most effective method for increasing the timelines of signatures on orders and positively impacting the patient care process would be

  1. performing a retrospective review where all orders can be flagged at one time.
  2. holding a printed order sheet on the medical care unit at least 24 hours post discharge to give the physician time to sign.
  3. developing an open-record review process.
  4. devising a signature sheet for the attending physician to sign prospectively that will apply to all orders given during the current episode of his patient’s care.

Question 79

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the

  1. peer review organization.
  2. National Practitioner Data Bank.
  3. risk manager.
  4. Health Plan Employer Data and Information Set.

Question 80

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

  1. reliability.
  2. accessibility.
  3. legibility.
  4. completeness.