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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
Data Governance - concerned with governing the input/data, establish policies and standards for data
quality, how data defined, captured, stored, structured, retrieved
Info Governance - concerned with governing the output/info, control and use of documents, reports,
records created from data
Hierarchy - data, info, knowledge, wisdom
Data Life Cycle Mgt - data planning, inventory, evaluation, capture, transformation, processing, access,
maintenance, destruction, etc, determining what data collected and how, standards for data retention
and storage
Content Mgt - managing both structured and unstructured data
Business Intelligence - broad category of apps and tech for gathering, storing, analyzing, providing access
to data to help users make better business decisions
Stakeholder Analysis - process that identifies and analyses the attitudes/opinions of stakeholders
ACS - American College of Surgeons, provides impetus for standardizing health records, minimum
standards in 20th century,
JC - Joint Commission, an accrediting body, voluntary holds to standards and proves they are capable of
those standards, holds surveys, tracer methodology, can be individualizing or system, focusing on high
risks, review health records also
Medicare COP - CMS, division of federal Dept HHS, developing and enforcing regulations regarding to
Medicare participation, regulations for content/documentation, requirements and standards
, Internal Standards - bylaws, rules, regulations relating to the medical staff/facility, approved by board,
Longitudinal Health Record - compiled about an individual over time, various encounters from facilities,
HIE projects doing a lot of it
MRN - A unique identification number assigned by the hospital to each patient's medical record.
General vs implied consent vs informed - general is for routine touching, exams, care, and implied is
when patient implies consent like if in emergency, informed consent is when a surgeon has to present
patient w info/risks about surgery
History - CC-Chief complaint, why the patient is being admitted/seeking care
HPI: history of present illness, what patient thinks problem is
PMH: past medical history
Social/personal history: behaviors, etc
Family medical history: info about family that would be relevant with diseases, etc.
ROS: review of systems, questions to reveal symptoms, body parts
Physical - has to be completed H&P within 24 hrs of being admitted, or within past 30 days if completed,
but if within 30 days need updates if anything changed
Orders - orders written by medical staff regarding patient, medical orders, must demonstrate medical
necessity, sig, title, time and date of order, can accept tele-orders if approved provider and
authenticated, prompt authentication, JC recommends writing in policies/procedures which personnel is
allowed to write orders or not
CPOE - Computerized Provider Order Entry, to enter in orders to decrease legibility issues
Special orders - DNR- must contain documentation of that decision made
Seclusion and restraint- must comply with regulations, only necessary to protect from harm
Progress Notes - chronological statements about patients care, response to treatment during stay
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