RHIA

RHIA practice questions, page 8 of 73, with answer review and explanations.

Question 36

For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and

  1. department.
  2. discipline.
  3. initials.
  4. supervising physician.

Question 37

In creating a new form or computer view, the designer should be most driven by

  1. QIO standards.
  2. medical staff bylaws.
  3. needs of the users.
  4. flow of data on the page or screen.

Question 38

Under which of the following conditions can an original patient health record by physically removed from the hospital?

  1. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital
  2. when the directory of health records is acting in response to a subpoena duces tecum and takes the health record to court
  3. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record
  4. when the record is taken to a physician’s private office for a follow-up patient visit postdischarge

Question 39

According to the following table, the most serious record delinquency problem occurred in

  1. April
  2. May.
  3. June
  4. cannot determine from this data. A

Question 40

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

  1. sciatica unimproved with hot pack therapy
  2. patient moving about very cautiously, appears to be in pain
  3. adjust pain medication; begin physical therapy tomorrow
  4. patient states low back pain is as severe as it was on admission