RHIA

RHIA practice questions, page 19 of 73, with answer review and explanations.

Question 91

One record documentation requirement shared by BOTH ascute care and emergency departments is

  1. patient’s condition on discharge.
  2. time and means of arrival.
  3. advance directive.
  4. problem list.

Question 92

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

  1. standing orders.
  2. telephone orders.
  3. stop orders.
  4. discharge order. D

Question 93

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document

  1. objective symptoms observed by the physician.
  2. past and current activities, such as smoking and drinking habits.
  3. a chronological description of patient’s present condition from time of onset to present.
  4. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.

Question 94

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets

  1. Joint Commission standards
  2. NHIN standards
  3. HL-7 standards
  4. CMS standards

Question 95

If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to

  1. date of birth.
  2. date of admission.
  3. social security number.
  4. mother’s maiden name.