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RHIA Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100% VerifiedHealth Record Matrix - Once the LHR is defined, it is best practice to create a health record matrix that
identifies and tracks the physical location of each paper document and the source of each electronic
document that constitutes the LHR. in addition to defining the content of the LHR, it is best practice to
establish a policy statement on the maintenance of it.
Data that is translated into standard nomenclature of classification so that it may be aggregated,
analyzed and compared. - Coded Data
MDS - minimum data set - a component of the resident assessment instrument (RAI) and used to collect
information about the resident's risk factors and to plan the ongoing care and treatment of the resident
in the long-term care facility
RAP - Resident assessment protocols - form a critical link to decisions about care planning and provide
guidance on how to synthesize assessment information within a comprehensive assessment. the triggers
target conditions for additional assessment and review, as warranted by MDS item responses. the RAPs
guidelines help facility staff evaluate triggered conditions
Documenting the full depth and breadth of data use in a healthcare entity requires: - identifying the
needs of data consumers - when tasked with assessing or managing data quality, an HIM professional
must first understand who the data consumers are. this involves making a list of all the internal and
external consumers. assessing the needs of data consumers is challenging; a good data manager would
ask the data consumer how they used the data rather than what their needs are. the data manager must
take a controlled and careful approach to collecting data for consumer needs. it will be impossible for
the data manager to meet all the needs of all the data consumers
authentication - an author is a person or system who originates or creates information that becomes
part of the record. each author must be granted permission by the healthcare entity to make such
entries. not all users will be granted authorship rights into all areas of the electronic health record. the
individual must have the credentials required by state and federal laws to be granted the right to
document observations and facts related to the provisions of healthcare services. authentication is a
process by which a user (a person or entity) who authored an EHR entry or document is seeking to
validate that they are responsible for the data contained within it.
, LHR disclosure consists of - the data, documents, reports, and information that comprise the formal
business records of any healthcare entity that are to be utilized during legal proceedings - the concept of
legal health records was created to describe the data, documents, reports and information that
comprise the formal business records of any healthcare organization that are to be utilized during legal
proceedings. understanding legal health records requires knowledge of not only what comprises
business records used as legal health records, but also the processes as well as the physical and
electronic systems used to manage these records
Device and media controls - HIPAA requires the implementation of policies and procedures for the
removal of hardware and electronic media that contain ePHI into and out of a facility. there are four
implementation specifications within this standard: disposal, media reuse, accountability and data
backup and storage.
history of cancer reported to employer? - yes, unless the employer has allowed for such exclusion
implied consent - refers to consent for medical treatment that is communicated through a person's
conduct or some other means besides words. implied consent includes emergency situations where an
individual may be unconscious or otherwise lacks capacity to communicate consent. in these cases,
consent is implied by the law rather than the patient's words or conduct.
most people-focused access safeguard - administrative
Darling v. Charleston Community Hospital - Corporate negligence
Corporate negligence - a legal doctrine that was established by a judicial decision handed down in the
1965 court case Darling v Charleston community hospital. the court in this cased ruled specifically that
hospital governing boards have a duty to institute a means to evaluate and council medical staff who
personally perform services on a patient that results in harm due to unreasonable risk. Hospitals may be
held liable when a member of the medical staff fails to meet established standards of patient care.
Privileged communication - a legal concept designed to protect the confidentiality between two parties
and is usually delineated by state law
Privacy - patient has the right to maintain control over certain personal information. right of a patient to
control disclosure of personal information
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