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Domain 1 - RHIT Exam Review 2024.
Guaranteed Reviewed Questions and
Answers. Grade A.
__________ data document the patient's health condition, diagnosis, and procedures performed as well as the healthcare treatment provided. -Administrative -Perceptual -Clinical -IT - ANSClinical __________ is where a patient is erroneously assigned another person's health record number. When this happens, patient information from both patients becomes commingled and care providers may make medical decisions based on erroneous information, increasing the legal risks to the healthcare organization and quality of care risks to the patient as well a. Overlap b. Overlay c. Duplicate d. Purge - ANSb. Overlay __________ typically refers to a metric or measure used to evaluate the performance, productivity, or quality of individual doctors within a healthcare organization. a. Physician index b. Master patient index c. Operation index d. Disease index - ANSa. Physician index
___________ is a software platform or system designed to manage the creation, storage, organization, retrieval, sharing, and security of electronic documents and files within an organization. a. Master patient index (MPI) b. Audit trail c. Case-mix management d. Electronic document management system (EMDS) - ANSd. Electronic document management system (EMDS) ____________ contains details about past illnesses, surgeries, injuries, and medical conditions are recorded. This section may also include information about family medical history, such as diseases that run in the family a. Medical history b. Pathology report c. Operation report d. Physical examination - ANSa. Medical history ____________ data include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information -Administrative -Perceptual -Clinical -IT - ANSAdministrative ____________ is the process of matching fields from one database to another. It's the first step to facilitate data migration, data integration, and other data management tasks. -Expression -Match typing
d. Clinical observation - ANSa. Problem list _____________ involves analyzing and categorizing patients into groups or "cases" with similar clinical characteristics, diagnoses, treatment needs, and expected resource consumption. a. Master patient index (MPI) b. Audit trail c. Case-mix management d. Electronic document management system (EMDS) - ANSc. Case-mix management _____________ is the overarching authority that ensures the cohesive operation and integration of all EIM domains. Data governance includes a formal organizational structure with both authority and responsibility for managing an organization's data assets a. Data governance b. Data quality management c. Data security management d. Master data management - ANSa. Data governance ______________ contains detailed information about the findings from a healthcare provider's physical assessment of a patient. Vital Signs, General Appearance, Review of systems, Other findings. a. Medical history b. Pathology report c. Operation report d. Physical examination - ANSd. Physical examination ______________ data sources are data collected or extracted from a primary data source and used for purposes other than their original intended use. ____________ data sources are frequently maintained in registries, databases or indexes, such as registries. One answer only.
-Secondary -Primary -Out of date -Federal - ANSSecondary data sources ______________ in healthcare typically refers to a metric or measure used to evaluate the efficiency and utilization of operating rooms (ORs) within a healthcare facility. The _______________ provides insights into how effectively OR resources are being utilized and managed to meet patient demand for surgical procedures. a. Physician index b. Master patient index c. Operation index d. Disease index - ANSc. Operation index ______________ is a process by which a government-associated agency gives individuals express permission to practice an occupation. _______________ acts as an endorsement that an individual has met minimum competency standards. Use one term. a. Accreditation b. Licensure c. Acceptance d. Approval - ANSb. Licensure ______________ moves beyond data and consists of sets of data that are related and have been placed in context, are filtered, manipulated, or formatted in some way and are useful to a particular task. a. Registries b. Information c. Knowledge d. System - ANSInformation
aspects of the healthcare system. Uses methods such as interviews, focus groups, observations, and document analysis. -Qualitive -Quantitative -Structured -Focused - ANSQualitive Examples: Patient Experience Research, Healthcare Provider Practices, Organizational Culture and Climate, Healthcare Policy Analysis, Patient Education and Health Promotion & Health Services Research. _______________ contains documentation of the ongoing clinical observations, assessments, interventions, and plans made by healthcare providers during patient encounters. It's written by healthcare professionals to track the advancement of disease and care over time. a. Consultation b. Medical history c. Physical examination d. Progress notes - ANSd. Progress notes _______________ is a non-profit, independent organization that accredits and certifies health care organizations and programs in the US. joint commission is recognized. nationwide as a symbol of quality* that reflects and organization's commitment to meeting certain performance standards. a. Commission on Accreditation of Rehabilitation Facilities b. American Osteopathic Association c. National Committee for Quality Assurance d. The Joint Commission - ANSd. The Joint Commission _______________ typically refers to a situation where two or more healthcare providers document information concurrently or redundantly within the same section or aspect of a patient's medical record. A person can have different unique identifiers (MR numbers) in different databases by mistake.
a. Overlap b. Overlay c. Duplicate d. Purge - ANSa. Overlap Overlap may occur when multiple healthcare providers, such as physicians, nurses, or specialists, simultaneously document their assessments, interventions, or observations within the same section of the EHR. For example, two physicians may document their independent assessments of a patient's condition in the progress notes section during a team rounding session. ________________ contains detailed information about a surgical procedure performed on a patient. a. Medical history b. Pathology report c. Operation report d. Physical examination - ANSc. Operation report ________________ is a chronological record of events or activities that have occurred within a system, application, or process. In the context of healthcare, an audit trail refers to a log or trail of electronic records that tracks all actions, changes, or accesses made to patient health information or electronic health records (EHRs). It serves as a security measure to monitor and track the use of sensitive data and ensure compliance with privacy regulations and organizational policies. a. Master patient index (MPI) b. Audit trail c. Case-mix management d. Electronic document management system (EMDS) - ANSb. Audit trail _________________ is an independent 501 nonprofit organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation.
d. Disease index - ANSd. Disease index ____________________ is Medicare's standard for hospitals and nursing homes. The goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy, a. ACHC b. Joint Commission c. AAAHC d. CARF - ANSb. Joint Commission _____________________ refers to the overall management, control, and oversight of an organization's data assets to ensure they are used effectively, securely, and in compliance with relevant regulations and policies. It encompasses the processes, policies, standards, and guidelines that govern how data is collected, stored, managed, shared, and used within an organization. -Control of data -Interoperability -Data governance -Management of data - ANSData governance _______________: These systems provide context-sensitive templates. Templates ensure that the appropriate data are collected and guide users in adhering to professional practice standards, in a timely manner. These might include nursing admission assessments, nursing progress notes, vital signs charting, intake and output records, and the like. Many hospitals begin their EHR implementation with these charting systems. -Narrative notes -point of care (POC) charting systems -Minimum Data Set (MDS) charting -SOAP for subjective, objective, assessment, plan, - ANSpoint of care (POC) charting systems
_____________(s) are the recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners and are usually conferred by a national professional organization dedicated to a specific area of healthcare practice a. Degree b. Certificate c. License d. Credential - ANSd. Credentials
ANS---------------------------------------------------------------------- A _____________ is a summary of the patient's problems from the nurse or other professional's perspective with a detailed proposal for interventions that may follow the assessment. A progress note with detailed treatment action steps. -care plan -Flow record -Surgical note -Vital signs record - ANScare plan A ______________ medical record typically refers to a patient's health record that has been reviewed, finalized, and officially closed by the healthcare provider or facility responsible for maintaining the record. a. Inactivated b. Purged c. Cleared d. Reactivated - ANSc. Cleared
-data governance network -Outside data network - ANSdata governance framework A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measures should be in place to minimize this data entry error? a. Access controls b. Audit trail c. Edit checks d. Password controls - ANSc. Edit checks Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is: a. Ambulatory Care Data Set b. Continuity of care record c. Minimum Data Set d. Uniform Hospital Discharge Data Set - ANSb. Continuity of care record The continuity of care record (CCR) standard (ASTM E2369-05) is a core data set of relevant administrative, demographic, and clinical information elements about a patient's health status and healthcare treatment. It was created to help communicate that information from one provider to another for referral, transfer, or discharge of the patient A critical early step in designing an EHR is to develop a(n) ________ in which the characteristics of each data element are defined. a. Accreditation manual b. Core content
c. Continuity of care record d. Data dictionary - ANSd. Data dictionary A data dictionary improves data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing. A critical early step in implementing the EHR is to develop a data dictionary A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report? a. Consultation b. Medical history c. Physical examination d. Progress notes - ANSa. Consultation The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? a. Vital signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record - ANSa. Vital signs record The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse, making it the best source to gather this type of information
a. CARF b. DEEDS c. UACDS d. UHDDS - ANSd. UHDDS The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on every inpatient A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record - ANSb. Delinquent record When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards A healthcare provider organization, when defining its legal health record must: a. Assess the legal environment, system limitations, and HIE agreements b. Determine what other healthcare provider organizations are doing c. Determine if a legal health record is needed d. Only include the paper components of the health record - ANSa. Assess the legal environment, system limitations, and HIE agreements As part of the process to identify the legal health record, the facility should assess the legal environment, system limitations, and HIE agreements
A healthcare system wants to map ICD-10-CM to ICD-9-CM. Which of the following would be true about this effort? a. ICD-10-CM would be considered the target system b. This is an example of reverse mapping c. This is an example of forward mapping d. This is an example of bidirectional mapping - ANSb. This is an example of reverse mapping A reverse map links two systems in the opposite direction, from the newer version of a code set to an older version A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as: a. Data precision b. Data consistency c. Data granularity d. Data comprehensiveness - ANSa. Data precision Data precision is the term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined. For example, a precise data definition related to gender would include three values: male, female, and unknown A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records
Some providers also use a SOAP format for their problem-oriented progress notes. A subjective (S) entry relates significant information in the patient's words or from the patient's point of view A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written? a. Assessment b. Objective c. Plan d. Subjective - ANSa. Assessment Some providers also use a SOAP format for their problem-oriented progress notes. Professional conclusions reached from evaluation of the subjective or objective information make up the assessment A nurse is responsible for which of the following types of acute-care documentation? a. Medication administration record b. Radiology report c. Operative report d. Therapy assessment - ANSa. Medication administration record Nurses maintain chronological records of the patient's vital signs (blood pressure, heart rate, respiration rate, and temperature) and separate logs that show what medications were ordered and when they were administered on the medication administration record (MAR) A patient's birth date and gender documented in the health record are examples of a data ________. a. Element b. Map
c. Dictionary d. Definition - ANSa. Element A data element can be a single or individual fact that represents the smallest unique subset of a larger database, sometimes referred to as the raw facts and figures A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data? a. Clinical data b. Authorization data c. Administrative data d. Consent data - ANSc. Administrative data A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data?a. Clinical datab. Authorization datac. Administrative datad. Consent data A patient's registration forms, personal property list, RAI, care plan, and discharge or transfer documentation would be found most frequently in which type of health record? a. Rehabilitative care b. Ambulatory care c. Behavioral health d. Long-term care - ANSd. Long-term care The following list identifies some of the most common components of long-term care records: registration forms including resident identification data, personal property list, history and physical and hospital records, advance directives, bill of rights, and other legal records, and RAI and care plan A record that fails quantitative analysis is missing the quality criterion of:
