ahima rhia practice test

Joint Comission requires the attending physician to countersign health record documentation that is
entered by

• A. interns or medical students.
• B. midwives.
• C. consulting physicians.
• D. physician partners.

The minimum length of time for retaining original medical records is primarily governed by

• A. Joint Commission.
• B. medical staff.
• C. state law.
• D. readmission rates.

The use of personal signature stamps for authentication of entries in a paper-based record requires
special measures to guard against delegated use of the stamp. In a completely computerized patient
record system, similar rmeasures might be utilized to govern the use of

• A. fingerprint signatures.
• B. voice recognition systems.
• C. expert systems.
• D. electronic signatures.

Discharge summary documentation must include

• A. a detailed history of the patient.
• B. a note from social services or discharge planning.
• C. significant findings during hospitalization.
• D. correct codes for significant procedures

The performance of ongoing record reviews is an important tool is ensuring data quality through
accurate health records. These reviews evaluate

• A. quality of care through the use of pre-established criteria.
• B. adverse effects and contraindications of drugs utilized during hospitalization.
• C. potentially compensable events.
• D. completeness, adequacy, and quality of documentation.

Ultimate responsibility for the quality and completion of entries in patient health records belongs to
the

• A. chief of staff.
• B. attending physician.
• C. HIM director.
• D. risk manager.

Quantitative and qualitative reviews performed on patient records by medical record personnel in
either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of

• A. retrospective deficiency analysis.
• B. special study audits.
• C. concurrent chart review.
• D. occurrence screening.

The foundation for communicating all patient care goals in long-term care settings is the

• A. legal assessment.
• B. labor and delivery record.
• C. interdisciplinary patient care plan.
• D. Uniform Hospital Discharge Data Set.

Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring
trends in delinquent health record percentages?

• A. Health Record Committee.
• B. Utilization Review Committee.
• C. Risk Management Committee.
• D. Joint Conference Committee.

A health record analyst needs to quickly compare all lab values during one hospitalization. The
paper-based health record format best suited for this purpose is

• A. problem-oriented.
• B. source-oriented.
• C. reverse chronological.
• D. integrated.