RHIT Exam Review Domain 1 Already Graded A+
Health Information Management
1. When reviewing the discharge patient abstracting module of a proposed new electronic health record
(EHR), which data set should a health record technician consult to ensure the system collects all
federally require...
1. When reviewing the discharge patient abstracting module of a proposed new electronic health record
(EHR), which data set should a health record technician consult to ensure the system collects all
federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care
hospital?
Answer: Uniform Hospital Discharge Data Set (UHDDS).
2. What is one purpose of vocabulary standards?
Answer: Standardizing medical terminology to avoid differences in naming various health conditions and
procedures.
3. What do patient care managers use the data documented in the health record to evaluate?
Answer: Patterns and trends of patient care.
4. What is a problem in Mrs. Smith's EHR that is discovered during an audit, where her date of birth is
recorded as 3/25/1948 but the numbers are transposed in reports?
Answer: Data consistency.
5. Where would a health data analyst find daily blood pressure readings for patients with a diagnosis of
hypertension who were treated on the medical unit within a two-week period?
Answer: Vital signs record.
,Record Content and Quality
6. What is a key characteristic of the problem-oriented health record?
Answer: Using an itemized list of the patient's past and present health problems.
7. Who must report communicable diseases to the state health department?
Answer: The facility, when a patient is diagnosed with one of the diseases from the health department's
communicable disease list.
8. What should be the HIM director's first step in ensuring data content standards are identified,
understood, implemented, and managed for the hospital's EHR system?
Answer: Identifying data content requirements for all areas of the organization.
Authentication and Documentation
9. What does data comprehensiveness refer to?
Answer: Ensuring patient data is reliable and comprehensive across the entire patient encounter.
10. Which clinical report would be the best source to gather daily blood pressure readings for patients
with a diagnosis of hypertension who were treated on the medical unit within a two-week period?
Answer: Vital signs record.
Data content standards allow organizations to collect data once and use it many times in many ways.
They also assist in data storage and mining as well as sharing data with external organizations for use in
benchmarking and other purposes.
, A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report?
a. Physician progress notes and medication record
b. Nursing and physician progress notes
c. Medication administration record and clinical laboratory reports
d. Physician orders and clinical laboratory reports ✔️c. Medication administration record and clinical
laboratory reports
Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test
was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin
was given after the PTT test was performed.
Which of the following is considered the authoritative resource in locating a health record?
a. Disease index
b. Master patient index
c. Patient directory
d. Patient registry ✔️b. Master patient index (MPI)
The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It
is used by the HIM department to look up patient demographics, dates of care, the patient's health
record number, and other information.
The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to
the proposed new codes for the next fiscal year and documenting variations in order to assess the
impact on the organization. This process creates a:
a. Data chargemaster report
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