Practice Questions for RHIT Exam:
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In which of the following examples does the gender of the patient constitute information
rather than a data element?
a. As an entry to be completed on the face sheet of the health record
b. In the note "50-year-old white male" in the patient history
c. In a study comparing the incidence of myocardial infarctions in black males as compared
to white females
d. In a study of the age distribution of lung cancer patients ✔✔c. In a study comparing
the incidence of myocardial infarctions in black males as compared to white females
Data are the raw elements that make up our communications. Humans have the innate ability
to combine data they collect and, through all their senses, produce information (which is data
that have been combined to produce value) and enhance that information with experience
and trial-and-error that produces knowledge. In this example, the gender is tied to race in the
data collection that constitutes information and not a data element.
A core data set developed by ASTM to communicate a patient's past and current
health information as the patient transitions from one care setting to another is:
,a. Ambulatory Care Data Set
b. Continuity of care record
c. Minimum Data Set
d. Uniform Hospital Discharge Data Set ✔✔b. Continuity of care record
The continuity of care record (CCR) standard (ASTM E2369-05) is a core data set of relevant
administrative, demographic, and clinical information elements about a patient's health status
and healthcare treatment. It was created to help communicate that information from one
provider to another for referral, transfer, or discharge of the patient.
The home health prospective payment system uses the ________ data set for patient
assessments.
a. HEDIS
b. OASIS-C
c. MDS
d. UHDDS ✔✔b. OASIS-C
The Outcomes and Assessment Information Set (OASIS-C) is a standardized data set designed
to gather data about Medicare beneficiaries who are receiving services from a home health
agency. OASIS-C includes a set of core data items that are collected on all adult home health
patients.
,A notation for a hypertensive patient in a physician ambulatory care progress note reads:
"Blood pressure adequately controlled." In which part of a problem-oriented health
record progress note would this be written?
a. Assessment
b. Objective
c. Plan
d. Subjective ✔✔a. Assessment
Some providers also use a SOAP format for their problem-oriented progress notes. Professional
conclusions reached from evaluation of the subjective or objective information make up the
assessment.
Which of the following provides a standardized vocabulary for facilitating the development of
computer-based patient records?
a. Current Procedural Terminology
b. Healthcare Common Procedure Coding System
c. International Classification of Diseases, Tenth Revision, Clinical Modification
d. Systematized Nomenclature of Medicine Clinical Terminology ✔✔d.
Systematized Nomenclature of Medicine Clinical Terminology
, Standardized vocabulary is needed to facilitate the indexing, storage, and retrieval of patient
information in an electronic health record (EHR). Systematized Nomenclature of Medicine
Clinical Terminology (SNOMED CT) creates a standardized vocabulary. The Computerbased
Patient Record Institute (CPRI) has studied the ability of current nomenclatures to capture
information for EHRs. The institute has determined that SNOMED CT is the most
comprehensive controlled vocabulary for coding the contents of the health record and
facilitating the development of computerized records.
The data set designed to organize data about public health issues to inform purchasers and
consumers about the performance of healthcare plans is:
a. UHDDS
b. DEEDS
c. MDS
d. HEDIS ✔✔d. HEDIS
The Healthcare Effectiveness Data and Information Set (HEDIS) is sponsored by the National
Committee for Quality Assurance (NCQA). HEDIS is a set of standard performance measures
designed to provide healthcare purchasers and consumers with the information they need
to compare the performance of healthcare plans
Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge
summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is
missing from Mrs. Smith's health record?
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