RHIT Domain 1 Exam Questions Answered Correctly Latest update 2025
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 activi...
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). - Answers 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
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). - Answers 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
b
In a forward map, an older version of a code set is mapped to a newer version (Amatayakul 2016, 285). -
Answers 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
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). - Answers 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
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). - Answers 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
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). - Answers 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
b
The quantitative analysis or record content review process can be handled in a number of ways. Some
acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using
this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review
each patient's record. This type of process is usually referred to as a concurrent review because review
occurs concurrently with the patient's stay in the hospital (Sayles 2016b, 64). - Answers 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 present
c. Retrospectively review each patient's health record to make sure that history and physicals are
present
d. Write a memorandum to all physicians relating the Joint Commission requirements for documenting
history and physical examinations
a
The health record typically begins in patient registration with the capture of patient demographic
information. The health record is assigned to new patients during the patient registration process. The
HIM department works with patient registration to ensure the quality of the data collected and to
correct duplicate and other issues with the MPI (Sayles 2016b, 74). - Answers The patient registration
department assists the HIM department in what way?
a. Assigning the health record number
, b. Processing the healthcare claim
c. Implementing the information systems used by the HIM department
d. Maintaining the information systems used by the HIM department
d
Information usually documented in the physical examination includes vital signs and examinations of the
head, eyes, ears, nose, throat (HEENT) (Brickner 2016, 91-92). - Answers The following is documented in
an acute-care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No
obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this
documentation appear?
a. Medical history
b. Pathology report
c. Operation report
d. Physical examination
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). - Answers The act of granting approval to a healthcare organization based on whether the
organization has met a set of voluntary standards is called:
a. Accreditation
b. Licensure
c. Acceptance
d. Approval
c
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