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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified

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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified

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  • August 25, 2024
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RHIA Domain 1 Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%
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Data Governance - concerned with governing the input/data, establish policies and standards for data
quality, how data defined, captured, stored, structured, retrieved



Info Governance - concerned with governing the output/info, control and use of documents, reports,
records created from data



Hierarchy - data, info, knowledge, wisdom



Data Life Cycle Mgt - data planning, inventory, evaluation, capture, transformation, processing, access,
maintenance, destruction, etc, determining what data collected and how, standards for data retention
and storage



Content Mgt - managing both structured and unstructured data



Business Intelligence - broad category of apps and tech for gathering, storing, analyzing, providing access
to data to help users make better business decisions



Stakeholder Analysis - process that identifies and analyses the attitudes/opinions of stakeholders



ACS - American College of Surgeons, provides impetus for standardizing health records, minimum
standards in 20th century,



JC - Joint Commission, an accrediting body, voluntary holds to standards and proves they are capable of
those standards, holds surveys, tracer methodology, can be individualizing or system, focusing on high
risks, review health records also



Medicare COP - CMS, division of federal Dept HHS, developing and enforcing regulations regarding to
Medicare participation, regulations for content/documentation, requirements and standards

, Internal Standards - bylaws, rules, regulations relating to the medical staff/facility, approved by board,



Longitudinal Health Record - compiled about an individual over time, various encounters from facilities,
HIE projects doing a lot of it



MRN - A unique identification number assigned by the hospital to each patient's medical record.



General vs implied consent vs informed - general is for routine touching, exams, care, and implied is
when patient implies consent like if in emergency, informed consent is when a surgeon has to present
patient w info/risks about surgery



History - CC-Chief complaint, why the patient is being admitted/seeking care

HPI: history of present illness, what patient thinks problem is

PMH: past medical history

Social/personal history: behaviors, etc

Family medical history: info about family that would be relevant with diseases, etc.

ROS: review of systems, questions to reveal symptoms, body parts



Physical - has to be completed H&P within 24 hrs of being admitted, or within past 30 days if completed,
but if within 30 days need updates if anything changed



Orders - orders written by medical staff regarding patient, medical orders, must demonstrate medical
necessity, sig, title, time and date of order, can accept tele-orders if approved provider and
authenticated, prompt authentication, JC recommends writing in policies/procedures which personnel is
allowed to write orders or not



CPOE - Computerized Provider Order Entry, to enter in orders to decrease legibility issues



Special orders - DNR- must contain documentation of that decision made

Seclusion and restraint- must comply with regulations, only necessary to protect from harm



Progress Notes - chronological statements about patients care, response to treatment during stay

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