Rhia domain 1 test - Study guides, Class notes & Summaries

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 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 Reco...

RHIA Domain 1 Test Questions with Correct Answers Compromising Authorship Integrity - Answer-Borrowing records from other sources Displaying past documentation as present Occlusion - Answer-Restricting blood flow Backlog in transcription - Answer-Write a detailed note about procedure Provider examines patient at request of another provider - Answer-Consultation Report In the absence of data dictionary - Answer-Establish data dictionary policy with associated standards Destructio...

What programs does TJC accredit? - Answer Ambulatory, behavioral, critical access hospitals, homeware, hospital, laboratory, nursing care centers, physician offices, and office-based surgery centers The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements - Answer Certification

Integrated Health Record - Answer arranged in strict chronological order, by date info entered, date of service, better story of patients care, over time, physicians office use the format usually Transcription - Answer transcribe the dictation by providers Digital Dictation - Answer voice sounds recored/converted into digital format

RHIA Domain 1 Test Questions with Complete Solutions Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following? - Answer-metadata A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called - Answer-charting by exception A 65 year old white male was admitted tot the hospital on 1/15 complaining of abdominal pain...

hy is the accurate collection of clinical data important? - Answer It becomes the basis of care plans and helps determine medical necessity Hybrid Record - Answer Using paper in conjunction with Electronic Health Records Why are hybrid records difficult to manage? - Answer Because what's in paper and what's electronic may constantly be changing while the organization will have to comply with regulations for both paper and electronic health records

Principal Function of Health Records - Answer Repository of clinical documentation relevant to patient care Common form of problem-oriented format - Answer SOAP form of progress notes ER Record - Answer Time and means of arrival Treatment record Discharge instructions

When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a: - Answer health record matrix identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR - Answer health record matrix

Henry experienced sudden sharp chest pain that he described as heavy and crushing. His pain and past medical history caused Dr. James to suspect that Henry was having an acute myocardial infarction (AMI). Which of the following tests is a more specific marker for an AMI? CK-MB (creatine kinase-muscle/brain) LDH1 (lactate dehydrogenase Isoenzymes test-1) Troponin I AST (aspartate aminotransferase) - Answer CK-MB

RHIA AHIMA PRACTICE TEST EXAM 2024 WITH 100% CORRECT ANSWERS Processing - correct answer Domain 2 Classifying, sorting, storing and retrieving data are all characteristics of which system component? 1. Output 2. Feedback 3.Processing 4.Input K81.2, OFT40ZZ, OFJ44ZZ - correct answer Domain 1 The patient is taken to the OR for a laparoscopic gallbladder removal secondary to acute and chronic cholecystitis. The surgeon encounters difficulty secondary to the patients body habitus and ...