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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Domain 1 Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%Verified
a detailed form with guidelines for assessing residents in long-term care facilities; also details what to do
if resident problems are identified - Minimum Data Set (MDS)
Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals.
Minimum set of items based on standard definitions to provide consistent data for multiple users.
Required for reporting Medicare and Medicaid patients.
Many other health care payers also use most of the UHDDS for the uniform billing system. - Uniform
Hospital Discharge Data Set (UHDDS)
An organization that accredits health care organizations and programs - The Joint Commission (TJC)
federal agency within the US Dept of Health and Human Services. Known for its operational oversight of
the Medicare program and in collaboration with state government programs.
Also plays an important regulatory role in an organizations medical staff makeup and the content of the
medical staff bylaws - CMS
The set of standards defined by the CMS Incentive Programs that governs the use of EHRs and allows
eligible providers and hospitals to earn incentive payments by meeting specific criteria - Meaningful Use
(MU)
Meaningful Use Stages - Stage 1: Data capture and sharing
Stage 2:Advance clinical processes
Stage 3:Improved outcomes
Additional privacy regulations on top of HIPAA, breach notification rules & stiffer civil and criminal
penalties for security violations - HITECH Act
,Requires a facility to maintain a single case record for any patient it admits. - CARF
-oversees most clinical and administrative data such as demographics, reports, claims, and orders
-holds patient full medical information from hospital billing to the inpatient ordering system
-is the standard generally used in communication between the hospital information system (HIS) and
the RIS - HL-7 (health level 7)
When are pharmacy consults required? - For elderly patients who take multiple medications
What setting are these data sets used in?
MDS
UHDDS
OASIS
DEEDS - MDS- long term care
UHDDS- acute, short, long term care in hospitals
OASIS- home health
DEEDS- ED
Standards governing the practice of medical staff members; typically voted upon by the organized
medical staff and the medical staff executive committee and approved by the facility's board; governs
the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide
by these bylaws in order to continue practice in the healthcare facility - Medical staff bylaws
the administrative policy and procedure requirements and operational guidelines (how the policies and
procedures are carried out) under which facilities are allowed to take part in the Medicare and Medicaid
programs- CMS dictates medical staff bylaws must address certain documentation requirements - CMS
Conditions of Participation
When must a medical history and physical (H&P) be documented? - For every patient no more than 30
days before or 24 hours after admission to the hospital
, Components of _________: chief complaint, past and present illnesses, family history, social history, and
review of body systems must be documented prior to surgery/ procedure requiring anesthesia - medical
history and physical (H&P)
CMS CoPs and CFCs (conditions for coverage) ensure: - patient care quality, safety, and improvement of
clinical outcomes
Standards applied to facilities that choose to participate in federal government reimbursement
programs such as Medicare and Medicaid - Conditions for Coverage (CFCs)
If healthcare organizations want to participate in federal government reimbursement programs, they
must at least demonstrate they meet the: - CFCs and CoPs
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions
of Participation - Deemed status
What programs does TJC accredit? - Ambulatory, behavioral, critical access hospitals, homeware,
hospital, laboratory, nursing care centers, physician offices, and office-based surgery centers
The process by which a duly authorized body evaluates and recognizes an individual, institution, or
educational program as meeting predetermined requirements - Certification
a piece of legislation written and approved by a state or federal legislature and then signed into law by
the state's governor, or President of the United States - Statute
Purpose of the legal health record (3) - 1. To support decisions made in the course of treating a patient,
2. support documentation for the revenue pursued by payers,
3. and documentation used for legal testimony related to the patient's disease, injury, treatment, the
decisions related to it and the response to it
If an organization meets TJC accredited deemed status survey, they are also deemed to have met the
__________ requirements - CMS
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