RHIA practice questions, page 17 of 73, with answer review and explanations.
Question 81
Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be
written within 24 hours of the patient’s admission.
accepted by a charge nurses only.
co-signed by the attending physician within 12 hours of giving the order.
accepted by persons authorized by hospital regulations and procedures.
Question 82
The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave
documented in an incident report and filed in the patient’s health record.
reported as a potentially compensable event.
reported to the Executive Committee.
documented in both the progress notes and the discharge summary
Question 83
Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, updated, and recertify the patient as appropriate. The time frame for requiring this summary is at least every
week.
month.
60 days.
90 days.
Question 84
You want to review the one document in your facility that will spell out the documentation requirements for patient records; designate the time frame for completion by the active medical staff; and indicate the penalties for failure to comply with these record standards. Your best resource will be
medical staff bylaws.
quality management plan.
Joint Commission accreditation manual.
medical staff rules and regulations.
Question 85
A quarterly review reveals the following data for Springfield Hospital: What is the percentage of incomplete records during this quarter?