RHIA

RHIA practice questions, page 3 of 73, with answer review and explanations.

Question 11

Discharge summary documentation must include

  1. a detailed history of the patient.
  2. a note from social services or discharge planning.
  3. significant findings during hospitalization.
  4. correct codes for significant procedures

Question 12

The performance of ongoing record reviews is an important tool is ensuring data quality through accurate health records. These reviews evaluate

  1. quality of care through the use of pre-established criteria.
  2. adverse effects and contraindications of drugs utilized during hospitalization.
  3. potentially compensable events.
  4. completeness, adequacy, and quality of documentation.

Question 13

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

  1. chief of staff.
  2. attending physician.
  3. HIM director.
  4. risk manager.

Question 14

Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of

  1. retrospective deficiency analysis.
  2. special study audits.
  3. concurrent chart review.
  4. occurrence screening.

Question 15

The foundation for communicating all patient care goals in long-term care settings is the

  1. legal assessment.
  2. labor and delivery record.
  3. interdisciplinary patient care plan.
  4. Uniform Hospital Discharge Data Set.