AHIMA RHIA Exam Questions

Question 6 of 1826

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

A.

interdisciplinary patient care plan.

B.

discharge summary.

C.

transfer record.

D.

problem list.

Question 7 of 1826

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

A.

it is too easy to delegate use of computer passwords.

B.

evidence cannot be provided that the physician actually reviewed and approved each report.

C.

electronic signatures are not acceptable in every state.

D.

tampering too often occurs with this method of authentication.

Question 8 of 1826

As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

A.

prenatal record.

B.

labor and delivery record.

C.

postpartum record.

D.

discharge summary.

Question 9 of 1826

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman.

A.

a new H&P is required for every inpatient admissions.

B.

that you apologize for not noticing the H&P she provided.

C.

the H&P copy is acceptable as long as she documents any interval changes.

D.

Joint Commission standards do not allow copies of any kind in the original record.

Question 10 of 1826

As a new CTR, you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility’s

A.

disease index.

B.

number control index.

C.

physicians’ index.

D.

patient index.