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RHIT EXAM STUDY GUIDE (SAYLES)
LATEST UPDATED
American College of Surgeons - ANS-The hospital standardization movement was inaugurated by the: Changes in technology - ANS-The HIM profession is changing due to: Information focused - ANS-The new model of HIM practice is: Department based - ANS-The traditional model of HIM practice was: CAHIIM - ANS-The organization that accredits HIM education programs is: Candidacy - ANS-Our college has applied to become accredited by CAHIIM. Which of the following is the name of the interim stage of accreditation? Engage - ANS-f the following is the virtual network used by AHIMA members? House of Delegates - ANS-Which of the following functions governs the HIM profession? Foster professional development of it's members. - ANS-The primary focus of AHIMA is to: Registered Health Information Technician - ANS-Which of the following certifications is administered by CCHIIM? Integrated Delivery Systems - ANS-The acronym IDS refers to: Physician assistant - ANS-Which healthcare professional assists physicians in clinical assessments and patient education? Cardiology - ANS-Which of the following medical practitioner is not considered a generalist? American Recovery and Reinvestment Act - ANS-Which of the following laws created the HITECH Act?
Tax Equity and Fiscal Responsibility Act of 1982. - ANS-An HIM student has asked you why Medicare reimburses healthcare providers through prospective payment systems. Which of the following pieces of legislation would you use as your explanation? ARRA - ANS-Which of the following legislation authorized the creation of the Office of National Coordinator for Health Information Technology? Utilization Review Act of 1977 - ANS-Required that hospitals conduct continued-stay reviews for Medicare and Medicaid patients. Public Law 92-603 of 1972 - ANS-Required concurrent review of Medicare and Medicaid patients. Patient Protection and Affordable Care Act of 2010 - ANS-Provided an individual mandate to have minimum acceptable coverage or pay a tax penalty. Social Security Act of 1935 - ANS-Gave the states funds on a matching basis for maternal and infant care, rehabilitation of crippled children, general public health work, and aid for dependent children under age 16. Tax Equity and Fiscal Responsibility Act of 1982 - ANS-Required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement. HIM - ANS-Which of the following is NOT an example of an administrative support services? Board of Directors - ANS-Who has the primary responsibility to guide the direction of the hospital? VA - ANS-Which of the following is an example of a federally run hospital? Clinical privileges - ANS-Dr. Smith has been granted permission by community hospital to perform cardiac catherizations. This permission is called? TRUE - ANS-True/False: Acute-care hospitals provide short0term care to diagnose or treat an illness. TRUE - ANS-Ture/False: Pharmaceutical services are considered part of the clinical support services. TRUE - ANS-True/False: The average length of stay for an acute-care hospital is 25 days or less. TRUE - ANS-True/False: Physical therapists are only one member of the rehabilitation service team.
TRUE - ANS-True/False: The American healthcare system is not developed from a master plan but is instead a patchwork quilt of measures passed not from thought as to how it would affect the whole, but rather based on idiology. Much attention today is focused on the cost of healthcare often at the expense of patient access and the quality of care provided. TRUE - ANS-True/False: Healthy People 2020 is the third iteration of this discount. TRUE - ANS-True/False: Comparative effectiveness research is a major focus of the Patient-Centered Outcomes Research Institute. Patient care - ANS-An example of a the primary purpose of the health record. Research - ANS-What organization utilizes health record data to prove or disapprove the efficacy of a healthcare treatment? Third party payer - ANS-Which of the following is an example of an institutional user of the healthcare? Patient - ANS-Which of the following is an example of an individual user? Public health and research - ANS-Health departments use the health record to monitor outbreaks of diseases. Which type of use is this? Roll - ANS-What microfilm format is inefficient when patients have multiple admissions on microfilm? Mobile filing units - ANS-What type of paper-based storage system conserves floor space by eliminating all but one or two aisles? Color coding - ANS-What feature of the filing folder helps locate misfiles within the paper-based filing system? Outguide - ANS-Which of the following is a tool used to track paper-based health records? Corrective action should be taken. - ANS-What should be done when the HIM departments error or accuracy rate is too high based on policy? Assembly - ANS-In a paper-based system, individual health records are organized in a standardized order in which of the following processes? Analysis - ANS-Reviewing a health record for missing signatures and missing medical reports is called
Overlay - ANS-Two patients' records were filed together by mistake. This is an example of: Delinquent records - ANS-Which of the following describes incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies? Control workflow - ANS-One of the advantages of a DMS is that it can: The amendment must have a separate signature, date, and time. - ANS-How are amendments handled in the EHR? Policies and procedures to control which version(s) is displayed. - ANS-Version control of documents in the EHR requires: Personal health record - ANS-Which of the following is controlled by the patient? Electronic health record - ANS-Where will you find clinical decision support? Release of information - ANS-Which of the following systems is used to track whether or not a request for information has been processed? Quality Improvement - ANS-With which department does the HIM department interact to perform audits and monitor outcomes? Front-end - ANS-What type of speech recognition is used when the physician edits the document? To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient. - ANS-The overall goal of documentation standards is: The Conditions of Participation - ANS-A hospital that participates in the Medicare and Medicaid programs must follow: Assess the legal environment. - ANS-When defining its legal health record, a healthcare provider organization must do which of the following? Medical history - ANS-Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists the patient's past medical, personal and family history? All categories of healthcare records. - ANS-General documentation guidelines apply to: TRUE - ANS-True/False: Health record entries should be documented at the time the services they describe are rendered.
Problem-oriented health record - ANS-The subjective, objective, assessment plan (SOAP) method came from the: The set of functions created by an organization to plan, organize, and coordinate the people, processes, technology and content needed to manage information for the purposes of data quality, patient safety and ease of use. - ANS-Enterprise information management is: TRUE - ANS-True/False: AHIMA and data governance is an essential component of daily operations, the ability to understand, evaluate, and apply the different principles becomes an essential part of a successful information and data governance program. American College of Surgeons (ACS) - ANS-Which program was used to raise the standards of surgery by establishing minimum quality standards for hospitals? Commission on Accreditation for Health Informatics and Information Education (CAHIM)
- ANS-Accreditation programs are managed by: The accountability framework and decision rights to achieve enterprise information managment. - ANS-What is information governance? Board of directors - ANS-AHIMA's (blank) leads the volunteer structure and also is responsible for managing the association and determining direction and ensuring that the organization is fiscally sound. Healthcare Information and Management Systems Society (HIMSS) - ANS-This is a not- for-profit organization who is focused on better health through information technology (IT). American Academy of Professional Coders (AAPC) - ANS-Who educates and certifies medical coders? Continuum of care - ANS-This places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialist and ancillary providers. Integrated Delivery Networks (IDNs) - ANS-An (blank) comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to deliver health services. Managed care organizations (MCOs) - ANS-A type of healthcare organization that delivers medical care and manages all aspects of patient care or the payment for care by limiting providers of care, discounting payments to providers of care, or limiting access to care.
Documentation-imaging technology - ANS-Which of the following electronic record technological capabilities would allow paper-based health records to be incorporated into a patient's EHR? Problem-oriented health record. - ANS-The problem list is part of which of the following? It is known as imaging. - ANS-The paper health record has been scanned and is now available digitally. What is this known as? Objective - ANS-Nursing documentation within the health record will be: FALSE - ANS-True/False: Payers and the government are not concerned with how a physician documents in a health record. FALSE - ANS-True/False: Only physicians document in the health record. FALSE - ANS-True/False: HIM professionals document in the health record. TRUE - ANS-True/False: Management of health record information is a fundamental component of information governance. TRUE - ANS-True/False: If data granularity is the goal of collecting the data, clinical terminologies is the best choice. TRUE - ANS-True/False: The SNOWMED CT preferred term includes the semantic tag. TRUE - ANS-True/False: The three main core components of SNOWMED CT are concepts, descriptions, and relationships. TRUE - ANS-True/False: Category I CPT includes E/M, anesthesia, surgery, radiology pathology and laboratory, and medicine. TRUE - ANS-True/False: The purpose of nursing terminologies is to represent clinical information generated and used by nursing staff. RxNorm - ANS-Which of the following is standard for drugs under the Meaningful Use program? HCPCS - ANS-Which of the following is standard for supplies under HIPAA? LOINC - ANS-Which of the following is standard for clinical lab test results? Dental procedures - ANS-Which type of HCPCS Level II code is not published by CMS? Ingredients - ANS-RxNorm names for clinical drugs contain information on what?
Improved access, alerts, reminders, rapid access, facilitates coordination of care, structured data collection, comprehensive data and supports research and well as disease prevention and control. - ANS-What are the benefits of data stewardship? The assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. - ANS-What is data integrity? The capability of two or more information systems and software applications to communicate and exchange information. - ANS-What is interoperability? Standards development organizations which are private or government agencies that are involved in the creation and implementation of healthcare standards. - ANS-What are SDOs? These are standards that are developed in order to support and create structure with data exchange to sustain interoperability. - ANS-What are data interchange standards? The American National Standards Institute (ANSI) - ANS-SDO's are managed by: Information collected during day-to-day operations of a healthcare organization that has value within an organization. - ANS-Information assets refer to: Utilization review (UR) - ANS-This is the process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified. Health Insurance Portability and Accountability Act (HIPAA) - ANS-This program addresses issues related to the portability of health insurance afterleaving employment establishment of national standards for electronic healthcare transactions, and national identifiers for providers, health plans and employers. Health Information Technology for Economic and Clinical Health (HITECH) Act. - ANS- The act allocated funds for implementation of a nationwide health information exchange and implementation of electronic health records. Healthy People 2020 - ANS-This program sets out a plan to improve the nation's health with a vision of a society in which all people live long, healthy lives. The goals are: Attain high-quality, longer lives free of preventable disease, disability, injury and premature death. Hybrid health record - ANS-What is a combination of the paper record and the EHR? Enterprise master patient index (EMPI) - ANS-This process links the patient's information at the different facilities.
Serial numbering system - ANS-When a patient is issued a unique numerical identifier for every encounter at the healthcare facility. Unit numbering system - ANS-Used in large healthcare facilities as it does not have many of the inefficiencies of the serial numbering systems. Serial-unit numbering system - ANS-A combination of the serial and unit numbering systems. Alphabetic filing system - ANS-Typically used by small clinics and physician offices. Numeric filing system - ANS-This is where the health records are filed by the health record number. Straight numeric filing system - ANS-This files the records in straight numeric order based on the health record number. Terminal-digit filing system - ANS-This is the most efficient of the numeric filing system. Records are filed by the last two digits called the terminal digits and then the middle two digits as known as the secondary unit. This is effective for heavy record volume facilities. Alphanumeric filing system - ANS-Alphabetic and numeric characters are used to sort health records in this system. Centralized unit filing systems - ANS-All of the patient's encounters are filed together in a single location. Qualitative analysis - ANS-Monitoring the quality of documentation. Assembly - ANS-The process of ensuring that each page in the health record is organized in a standardized format.
