RHIT Prep Domain 1: Data Analysis and Management Already
Graded A+
Health Information Management
1. What is a crucial step in designing an electronic health record (EHR)?
Answer: Developing a data dictionary.
2. What led to the development of a standardized set of data elements for hospit...
RHIT Prep Domain 1: Data Analysis and Management Already
Graded A+
Health Information Management
1. What is a crucial step in designing an electronic health record (EHR)?
Answer: Developing a data dictionary.
2. What led to the development of a standardized set of data elements for hospital discharge abstracts?
Answer: The need to provide comparative data to hospitals.
3. What are two purposes of a data set?
Answer: Identifying data elements to be collected about each patient and providing uniform data
definitions.
4. Where should an HIT consultant start when designing a data collection form for an acute-care
hospital?
Answer: With the Uniform Hospital Discharge Data Set (UHDDS).
5. What is the purpose of the UHDDS?
Answer: To list and define a set of common, uniform data elements.
Record Content and Quality
, 6. What is the process called when deficiencies in health records are identified through analysis?
Answer: Identifying incomplete records.
7. In a paper-based system, where are incomplete records monitored?
Answer: In the incomplete file room.
8. What is the goal of completing a chart in a special area of the HIM department?
Answer: To ensure completeness.
Authentication and Documentation
9. What is authentication in a record?
Answer: Establishing its baseline trustworthiness.
10. How can coding managers address documentation issues with physicians failing to document cause
and effect of diabetes and its manifestations?
Answer: Educating medical staff on their roles in clinical documentation improvement and providing
documentation guidelines.
Assessment ✔️A(n) _____ entry in a SOAP note relates professional conclusions reached from
evaluation of the other information gathered during the encounter. Ex: "Blood pressure adequately
controlled."
Plan ✔️A(n) _____ entry in an a SOAP note relates diagnostic, therapeutic, and educational plans to
resolve the problem.
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