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RHIT DOMAIN 1: ESSENTIAL STUDY GUIDE
Which of the following individuals would serve as a bridge between information technology and business and clinical areas while managing each key area? a. Data steward b. Systems analyst c. Data scientist d. Systems administrator a Data stewards serve as the bridge between information technology, and business and clinical areas. They are assigned to manage key data areas and are responsible for tasks such as data definition and information quality activities (Johns 2015, 83). Which of the following data sets would be most helpful in developing a hospital trauma data registry? a. DEEDS b. MDS c. OASIS d. UACDS a In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital- based emergency departments and to reduce incompatibilities in emergency department records (Sharp 2016, 178; Giannangelo 2015, 255). Which of the following is the best definition of a forward map in data mapping? a. Linking of two systems in the opposite direction b. Linking an older version of a code set to a newer version c. Linking a newer version of a code set to an older version d. Linking a source system to a target system b In a forward map, an older version of a code set is mapped to a newer version (Amatayakul 2016, 285).
What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice? a. Degree b. Certificate c. License d. Credential d Credentials 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 (Shaw and Carter 2015, 336). 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 a As part of the process to identify the legal health record, the facility should assess the legal environment, system limitations, and HIE agreements (Brickner 2016, 86-87). Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? a. Minimum Data Set b. National Commission on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set c Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and thus must follow the Medicare Conditions of Participation (Brickner 2016, 84, 102). To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to make sure that history and physicals are
a Accreditation is the act of granting approval to a healthcare organization. The approval is based on whether the organization has met a set of voluntary standards that were developed by the accreditation agency. Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation or certification. The Joint Commission is an example of an accreditation agency (Shaw and Carter 2015, 406). A secondary purpose of the health record is to provide support for which of the following? a. Provider reimbursement b. Patient self-management activities c. Research d. Patient care delivery c The secondary purposes of the health record are not associated with specific encounters between patient and healthcare professional. Rather, they are related to the environment in which patient care is provided. Some secondary purposes are: support for research, to serve as evidence in litigation, to allocate resources, to plan market strategy, and the like (Sayles 2016b, 52-53). Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users? a. Controlled vocabulary b. Data exchange standards c. Encoded vocabulary d. Proprietary standards a The vocabulary used in an electronic health record (EHR) system should, at a minimum, be a controlled vocabulary, which is essential in ensuring a common meaning for all users. A controlled vocabulary means that a specific set of terms in the EHR's data dictionary may be used and that a central authority approves any additions or changes (Sayles 2016a, 4-7). Authentication of a record refers to: a. Establishment of its baseline trustworthiness b. The type of electronic operating system on which it was created c. The identity of the individual who notarized it d. Its relevance a Even if evidence appears to be relevant, it must also be authenticated. As with health records, the evidence itself must be shown to have a baseline authenticity or trustworthiness (Klaver 2017a, 78-79).
The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a. Have coders continue to query the attending physician for this documentation. b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c. Do nothing because coding compliance guidelines do not allow any action. d. Place all offending physicians on suspension if the documentation issues continue. b The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Foltz et al. 2016, 466). The advent of the EHR has increased the amount of documentation largely due to: a. Storage capabilities b. Joint Commission requirements c. Ease of entry d. Reporting c The advent of the electronic health record (EHR) came with improvements as well as challenges related to clinical documentation. Overall, the EHR has increased the amount of documentation based largely on the ease of entry (Hess 2015, 124). Which of the following is an example of clinical data? a. Admitting diagnosis b. Date and time of admission c. Insurance information d. Health record number a The health record generally contains two types of data: clinical and administrative. Clinical data document the patient's health condition, diagnosis, and procedures performed as well as the healthcare treatment provided. Administrative 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 (Brickner 2016, 90). Which of the following is an institutional user of the health record? a. A third-party payer
The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if: a. The template was defined b. The data type was numeric c. The field was not required d. The field length was longer a A pattern used in computer-based patient records to capture data in a structured manner is called a template. One benefit of using a template is to ensure data integrity upon data entry (Brinda 2016, 141; Sayles and Gordon 2016, 675). In a cancer registry, the accession number: a. Identifies all the cases of cancer treated in a given year b. Is the number assigned to each case as it is entered into a cancer registry c. Identifies the pathologic diagnosis of an individual cancer d. Is the number assigned for the diagnosis of a cancer patient that is entered into the cancer registry treatments and at different stages of cancer b When a case is first entered in the registry, an accession number is assigned. This number consists of the first digits of the year the patient was first seen at the facility, and the remaining digits are assigned sequentially throughout the year. The first case in the year, for example, might be 10-0001. The accession number may be assigned manually or by the automated cancer database used by the organization (Sharp 2016, 176). Why does an ideal EHR system require point-of-care charting? a. Eases duplicate data entry burden b. Eliminates intermediary paper forms c. Reduces memory loss d. Ensures that appropriate data are collected timely d Many hospitals begin their EHR implementation with point of care (POC) charting systems. These systems provide context-sensitive templates. Templates ensure that the appropriate data are collected and guide users in adhering to professional practice standards. These might include nursing admission assessments, nursing progress notes, vital signs charting, intake and output records, and the like (Giannangelo 2016b, 325-326). Which of the following is the best definition of system of record (SOR)? a. Authoritative source for data about an entity b. Master entity application
c. Exact match logic d. Primary data about an entity a Once the organization identifies sources, it lists the most trusted ones. Usually these are the sources with the most volume of master data records associated with a specific entity. In some instances, the master data will have their own unique system of record. A system of record is usually a specialized application system and the authoritative source for data about an entity (Johns 2015, 175). 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 a 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 (Brickner 2016, 96). Which of the following is the goal of the quantitative analysis performed by HIM professionals? a. Ensuring that the health record is legible b. Verifying that health professionals are providing appropriate care c. Identifying deficiencies early so they can be corrected d. Ensuring bills are correct c Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record (Sayles 2016b, 64). Which of the following indexes is an important source of patient health record numbers? a. Physician index b. Master patient index c. Operation index d. Disease index b The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information (Sayles 2016b, 56-57).
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 (Brinda 2016, 141). Which of the following statements best describes the difference between a hospital inpatient and a hospital outpatient? a. Outpatients are treated in the emergency department; inpatients receive services in the regular clinical departments of the hospital. b. Inpatients always stay in the hospital overnight; outpatients never do. c. Inpatients receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services. d. Outpatients primarily receive diagnostic services; inpatients receive mostly therapeutic services c A hospital inpatient is a person who is provided room, board, and continuous general nursing service in an area of the hospital where patients generally stay at least overnight. A hospital outpatient is a hospital patient who receives services in one or more of the outpatient facilities when not currently an inpatient or home care patient (Horton 2016b, 385). Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? a. Flow record b. Vital signs record c. Care plan d. Surgical note c A care plan is a summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions that may follow the assessment (Brickner 2016, 93). Cancer registries are maintained by hospitals: a. By federal law or state law b. Voluntarily or by state law c. Voluntarily or by federal law d. By mandate from the American College of Surgeons b Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many states require that hospitals report their data to a central state-wide registry or incidence surveillance program who in turn reports the data to the Centers for Disease Control (CDC) (Sharp 2016, 175 - 177). At the time a hospital implemented an electronic health record, the Health Record Committee determined that all records of patients who have not been treated at the facility in the past two years would be moved to an inactive file area. These patient records are considered ________ from the
active filing area. a. Inactivated b. Purged c. Cleared d. Reactivated b Files of patients who have not been at the facility for a specified period, such as two years, may be purged or removed from the active filing area. The time period and frequency of purging depends on the space available, patient readmission rate, and the need for access to the health record (Sayles 2016b, 61). Physician orders for DNR and DNI should be consistent with: a. Patient's advance directive b. Patient's bill of rights c. Notice of privacy practices d. Authorization for release of information a An advanced directive is a written document that provides directions about a patient's desires in relation to care decisions for use by health care workers if the patient is incapacitated or not capable of communication. Physician orders for "do not resuscitate" (DNR) and "do not attempt intubation" (DNI) should be consistent with the patient's advanced directives (Russo 2013a, 194, 196). Which of the following statements represents knowledge? a. Hematocrit is 48 today b. Mary Jones had a blood pressure of 120/ c. The hospital has an 89 percent occupancy rate d. Mary Jones's hemoglobin of 13 is within normal range d Knowledge consists of a combination of rules, relationships, ideas, and experiences applied to information. The statement "Mary Jones's hemoglobin of 13 is within normal range" identifies the patient, specific information about that patient and how it relates to normal parameters which makes it knowledge rather than information (Johns 2015, 25). Two patients' records were filed together by mistake. This is an example of: a. Overlap b. Overlay c. Duplicate d. Purge b
b. Amendments must be entered by the same person as the original note. c. Amendments cannot be entered after 24 hours of the event. d. The amendment must have a separate signature, date, and time. d Policies and procedures need to be in place to address amendments and corrections in the EHR. Once a document is authenticated, the document should be locked to prevent changes. In the event that an amendment, addendum, or deletion needs to be made, the document would need to be unlocked. The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made (Sayles 2016b, 70). A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical laboratory reports c Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after the PTT test was performed (Brickner 2016, 94). In data matching which of the following best describes an overlap? a. When one entity in a database has multiple unique identifiers b. When one entity is assigned another entity's unique identifier c. When one entity has different unique identifiers in different databases d. When one database overlaps with another database c An overlap is when one entity has different unique identifiers in different databases (Johns 2015, 177). Activities of daily living (ADL) are components of: a. OASIS-C b. UHDDS c. UACDS d. ORYX and RAPs a Outcomes and Assessment Information Set (OASIS-C) is a standardized data set of more than 30 data
elements designed to gather data about Medicare beneficiaries who are receiving services from a home health agency (White 2013, 557-560). Which of the following documentation must be included in a patient's health record prior to performing a surgical procedure? a. Consent for operative procedure, anesthesia report, surgical report b. Consent for operative procedure, history, physical examination c. History, physical examination, anesthesia report d. Problem list, history, physical examination b Documentation of health history, consents, and the physical examination must be available in the patient's record before any surgical procedures may be performed (Russo 2013a, 203-207). Multiple users entering data may have different definitions or perceptions about what goes into a data field, thereby confounding the data. For example, one department may use the term "PATIENT" while another department my use the term "CLIENT" to define the same entity. Which of the following would be used to provide standardization? a. Data dictionary b. Data mining c. Data model d. Database a The data dictionary is a central building block that supports communication across business processes. It improves data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing. For example, the data element "PATIENT" would have the same field length and definition across all applications in the organization (Brinda 2016, 141). Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an organization's data assets? a. Data governance b. Data quality management c. Data security management d. Master data management a Data governance 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 (Johns 2015, 70). Electronic systems used by nurses and physicians to document assessments and findings are called: a. Computerized provider order entry b. Electronic document management systems
c Quantitative analysis is used by health information management professionals as a method to detect whether elements of the patient's health record are missing, or not complete (Sayles and Trawick 2014, 37). In which department or unit is the health record number typically assigned? a. HIM b. Patient registration c. Nursing d. Billing b The health record number is a key data element in the MPI. It is used as a unique personal identifier and is also used in paper-based numerical filing systems to locate records and in electronic systems to link records. Although it is typically assigned at the point of patient registration, the HIM department is usually responsible for the integrity of health record number assignment and for ensuring that no two patients receive the same number (Sayles 2016b, 74). Patient care managers use the data documented in the health record to: a. Determine the extent and effects of occupational hazards b. Evaluate patterns and trends of patient care c. Generate patient bills and third-party payer claims for reimbursement d. Provide direct patient care b Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place (Sayles 2016b, 54). What type of registry maintains a database on patients injured by an external physical force? a. Implant registry b. Birth defects registry c. Trauma registry d. Transplant registry c Trauma registries maintain databases on patients with severe traumatic injuries. A traumatic injury is a wound or other injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall (Sharp 2016, 178). What is it called when accrediting bodies, such as the Joint Commission, rather than the government can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals? a. Deemed status
b. Licensure c. Subpoena d. Credentialing a Hospitals accredited through the Joint Commission or another accrediting body may participate in the Medicare program because the accrediting agency has been granted deemed status by the Medicare program. Deemed status means accrediting bodies such as the Joint Commission can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government (James 2013a, 447). The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear? a. Admission note b. Dietary note c. Physician progress note d. Social service note d This documentation would typically be found in social service notes (Fahrenholz 2013c, 660). Which of the following is a primary purpose of the health record? a. Document patient care delivery b. Regulation of healthcare facilities c. Aid in education of nurses and physicians d. Assist in process redesign a Patient care delivery is a primary purpose of the health record. Other primary purposes are patient care management, patient care support processes, financial and other administrative processes, and patient self-management (Sayles 2016b, 52). Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: a. Content and structure standards b. Security standard c. Transaction standards d. Vocabulary standards d Vocabulary standards are a list or collection of clinical words or phrases with their meanings; also the set
Which of the following is considered a clinical documentation best practice? a. Allowing clinicians to backdate physician orders b. Restricting use of abbreviations to a list approved by hospital and medical staff bylaws, rules, and regulations c. Allowing clinicians to delete documentation errors in an electronic record d. Prohibiting all verbal orders b Clinical documentation best practices establish policies and guidelines that ensure uniformity of both content and format of the patient record. One example of a clinical documentation best practice would be to stipulate abbreviations and symbols in the patient record to be permitted only when approved according to hospital and medical staff bylaws, rules, and regulations (Johns 2015, 13). What is the first step an organization should take when developing a data dictionary? a. Develop an approvals process b. Integrate common data elements c. Design a plan d. Ensure consistency c The data dictionary should be designed to accommodate changes resulting from clinical or technical advances and regulatory changes. There should be a plan for future expansion, such as expanding a data field from one element to multiple elements. This becomes problematic when comparing data across time if the meaning of a particular element has changed while its name or representation has not (Russo 2013b, 322). Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient? a. Ambulatory care b. Emergency care c. Long-term care d. Rehabilitative care b The emergency department record is a health record that is generated when a patient visits an emergency department (ED) seeking treatment. Documentation in the emergency department records includes the means by which the patient arrived at the healthcare facility and documentation of care provided to stabilize the patient (Brickner 2016, 100-101). Which of the following is characteristic of the legal health record? a. It must be electronic b. It includes the designated record set c. It is the record disclosed upon request d. It includes a patient's personal health record
c The legal health record distinction is important for several reasons. First, it is important to an organization's business and legal processes. Second, because the legal health record is the record that is produced upon request, including legal requests, it becomes important to ensure that the legal health record is legally sound and defensible as a valid document in legal situations (Rinehart-Thompson 2016a, 206). The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data? a. Laboratory b. Radiology c. Quality Management d. Registration a As the HIM department merges two duplicates together, the source system (laboratory) also must be corrected. This creates new challenges for organizations because merge functionality could be different in each system or module, which in turn creates data redundancy. Addressing ongoing errors within the MPI means an established quality measurement and maintenance program is crucial to the future of healthcare (Fahrenholz 2013b, 171). Dr. Jones comes into the HIM department and requests that the HIM director provides a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list? a. A disease index b. A master patient index c. An operative index d. A physician index a A disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period (Sharp 2016, 174). In designing an input screen for an EHR, which of the following would be best to capture structured data? a. Speech recognition b. Drop-down menus c. Natural language processing d. Document imaging b
