RHIA

RHIA practice questions, page 9 of 73, with answer review and explanations.

Question 41

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each resident as defined in the

  1. UHDDS.
  2. MDS.
  3. Uniform Clinical Data Set.
  4. Uniform Ambulatory Core Data.

Question 42

As the chair of a Forms Review Committee, you need to track the origin of data in a particular field and the security levels applicable to that field. Your best source for this information would be the

  1. facility’s data dictionary.
  2. MDS.
  3. Glossary of Health Care Terms.
  4. UHDDS.

Question 43

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

  1. interval summary.
  2. consultation report.
  3. advance directive.
  4. interdisciplinary care plan.

Question 44

An example of objective entry in the health record supplied by a health care practitioner is the

  1. past medical history.
  2. physical assessment.
  3. chief complaint.
  4. review of systems.

Question 45

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report be should be set at

  1. 12 hours after admission.
  2. 24 hours after admission.
  3. 12 hours after admission or prior to surgery.
  4. 24 hours after admission or prior to surgery.