RHIA Domain 1 Test with Complete Solutions
Why is data mapping necessary? - Answer-As health information systems and their use evolves, data mapping allows you to link disparate systems and data sets
What does the joint commission say about abbreviations? - Answer-Each healthcare orginization...
Why is data mapping necessary? - Answer-As health information systems and their use
evolves, data mapping allows you to link disparate systems and data sets
What does the joint commission say about abbreviations? - Answer-Each healthcare
orginization should strive to limit or eliminate the use of abbreviations by developing an
organization-specific abbreviation list so only those abbreviations approved by the
organization are used
Transfer Record - Answer-Created whenever a patient is transferred from one facility to
another
What does a transfer record contain? - Answer-1. Summary of care provided in the
facility being transfered from
2. Reason for transfer
Why is a transfer record important? - Answer-To continuum of care because it
documents communication between caregivers in multiple settings
Data Precision - Answer-Often relates to numerical data- denotes how close to an
actual size, weight, or other standard a particular measure is
Pathology Report - Answer-A document that contains the diagnosis determined by
examining cells and tissues under a microscope. The report may also contain
information about size, shape, and appearance of a specimen as it looks to the naked
eye
When can an Interval note be used for an H&P - Answer-May be used for the patient's
H&P when the patient is readmitted within 30 days of an initial treatment for the same
condition.
Interval Note - Answer-Health record documentation that describes the patient's course
between two closely related hospitalizations directed toward the treatment of the same
complaint when a patient has been discharged and readmitted within 30 days
DEEDS - Answer-Data Elements for Emergency Department Systems
Supports the uniform collection of data in hospital based emergency departments and to
substantially reduce incompatibilities in ED Records.
Verbal orders by telephone - Answer-Strongly discourages
, if necessary:
-the person receiving the order should read it back to ensure the accuracy
-Then order should be authenticated as soon as possible after it's given
Analog Data
Give example - Answer-Data or information that's not represented in an encoded,
computer-readable format
i.e: Photographic, chest film x-ray
Migration Path - Answer-A series of coordinated and planned steps required to move a
plan from one situation level to another
Responsibility of content, quality and signing Discharge Summaries - Answer-Attending
Physician
-a resident, PA or NP who is being supervised by an attending physician may complete
or dictate documentation but the attending is ultimately responsible for the content and
quality; therefor the attending MUST sign it.
Data Governance - Answer-an emerging practice in the healthcare industry. Decision
making and authority over data-related matters is data governance. It is clear that any
industry as reliant on data as healthcare needs a plan for managing this asset
Aggregate Data - Answer-used to develop information about groups of patients
Chief complaint - Answer-reason for the visit, nature or duration of the symptoms that
caused the patient's illness and caused the patient to seek medical attention as stated
in the patient's own words
Financial Data - Answer-includes insured party's member ID #, includes details about
patient's occupation, employer, and insurance coverage- healthcare providers use this
data to complete claims forms that will be submitted to 3rd party payers
Mask - Answer-Tells database what format to use to display the #s entered.
Entity-Relationship Diagram (ERD) - Answer-Developed to depict relational database
structures. Can also be used to depict conceptual level models for any type of
database; but would only be used to model a relational database at the logical level
SOAP - Answer-Subjective, Objective Assessment Plan notes
Part of problem-oriented medical record (POMR) approach most commonly used by
physicians and other healthcare professionals
intended to improve quality and continuity of client services by enhancing
communication among healthcare professionals
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