Here you have the best Ahima RHIA practice exam questions
In preparation for an HER, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is
The document includes a microscopic description of tissue excised during surgery, which is characteristic of a pathology report. A pathology report provides detailed information on the analysis of tissue samples taken during surgery, including both macroscopic and microscopic descriptions. This is different from a recovery room record, operative report, or discharge summary, which serve other purposes in documenting patient care.
Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but not in the UHDDS would be
The Minimum Data Set (MDS) is used in long-term care settings, such as nursing homes, and is focused on assessing a patient's clinical and functional status. Cognitive patterns are a key data element collected in the MDS as they help evaluate the mental status and needs of residents. In contrast, the Uniform Hospital Discharge Data Set (UHDDS) is used in hospitals and focuses on elements such as personal identification, procedures and dates, and principal diagnosis, which are vital for inpatient care and discharge planning. Therefore, cognitive patterns are expected to be collected in the MDS but not in the UHDDS.
A good first step toward protecting the security of data contained in a health information computer system would be to
A good first step toward protecting the security of data contained in a health information computer system would be defining levels of security for different types of information, depending on sensitivity. This approach ensures that more sensitive information is protected with higher security measures, reducing the risk of data breaches and unauthorized access.
In the number "99-0001" listed in a tumor registry accession register, what does the prefix "99" represent?
The prefix '99' in the number '99-0001' listed in a tumor registry accession register denotes the year the case was entered into the database of the registry. Typically, registries use a two-digit prefix to indicate the year of accession so they can easily identify and sort cases by the year they were registered.
A risk manager needs to locate a full report of a patients fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the
The most appropriate place to look for a full report of a patient's fall, including witness reports and probable reasons for the fall, would be the incident report. Incident reports are specifically designed to document any unusual occurrences or accidents, including patient falls, and contain detailed accounts of the event from various perspectives, including witness statements and assessments of causative factors.