Registered Health Information Administrator v1.0
Question 1
As the Data Security Officer for your institution, you plan to implement a log-on process for electronic signing that is LEAST susceptible to improper delegation of use. The method you will recommend is
- A. password assigned by system administrator.
- B. password assigned by user.
- C. biometrics-based identifier.
- D. encryption.
Answer : C
Question 2
In determining your acute care facilitys degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the
- A. CARF manual.
- B. hospital bylaws.
- C. Joint Commission accreditation manual.
- D. Federal Register.
Answer : D
Question 3
In an acute care hospital, a complete history and physical may not be dictated for a new admission when
- A. the patient is readmitted for a similar problem within 1 year.
- B. the patient’s stay is less than 24 hours.
- C. the patient has an uneventful course in the hospital.
- D. a legible copy of a recent H&P performed in the attending physician’s office is available.
Answer : D
Question 4
You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?
- A. Minimum Data Set
- B. Uniform Hospital Discharge Data Set
- C. Conditions of Participation
- D. Federal Register
Answer : B
Question 5
Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should
- A. complete a new cancer abstract.
- B. assign a new accession number.
- C. updated the follow-up file.
- D. complete a new master index file.
Answer : C
Question 6
When developing a data collection system, the most effective approach first considers
- A. the end user’s needs.
- B. applicable accreditation standards.
- C. hardware requirements.
- D. facility preference.
Answer : A
Question 7
A key data item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record is the
- A. physical findings.
- B. lab and diagnostic test results.
- C. time and means of arrival.
- D. instructions for follow-up care.
Answer : C
Question 8
A data item to include on a qualitative review checklist of infant and children inpatient health records which need not be included on adult records would be
- A. chief complaint.
- B. condition on discharge.
- C. time and means of arrival.
- D. growth and development record.
Answer : D
Question 9
For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and
- A. department.
- B. discipline.
- C. initials.
- D. supervising physician.
Answer : B
Question 10
In creating a new form or computer view, the designer should be most driven by
- A. QIO standards.
- B. medical staff bylaws.
- C. needs of the users.
- D. flow of data on the page or screen.
Answer : C
Question 11
Under which of the following conditions can an original patient health record by physically removed from the hospital?
- A. 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
- B. when the directory of health records is acting in response to a subpoena duces tecum and takes the health record to court
- C. 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
- D. when the record is taken to a physician’s private office for a follow-up patient visit postdischarge
Answer : B
Question 12
According to the following table, the most serious record delinquency problem occurred in
- A. April
- B. May.
- C. June
- D. cannot determine from this data. A
Answer : Explanation
Question 13
Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.
- A. sciatica unimproved with hot pack therapy
- B. patient moving about very cautiously, appears to be in pain
- C. adjust pain medication; begin physical therapy tomorrow
- D. patient states low back pain is as severe as it was on admission
Answer : D
Question 14
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
- A. UHDDS.
- B. MDS.
- C. Uniform Clinical Data Set.
- D. Uniform Ambulatory Core Data.
Answer : B
Question 15
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
- A. facility’s data dictionary.
- B. MDS.
- C. Glossary of Health Care Terms.
- D. UHDDS.
Answer : A