RHIA Domain 1 Exam 1 Study Set
Exam Questions and Answers 100%
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Mildred Smith was admitted to a nursing facility with the following information:
"Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis
her medical information was listed along with a summary of the care already
provided. This information is documented on the:
a.) Admitting physical evaluation record
b.) Patient's rights acknowledgement form
c.) Release of Information form
d.) Transfer Record - CORRECT ANSWER-D. Transfer Record
For further explanation look at page 160
A 65 y/o white male was admitted to the hospital on a 1/15 complaining of
abdominal pain. The attending physician requested an upper GI series and a
laboratory evaluation of CBC and UA. The X-ray revealed possible cholelithiasis
and the UA showed an increase in white blood cell count. The patient was taken to
,surgery for an exploratory laparoscopy and a ruptured appendix was discovered.
The chief complaint was:
a. Abdominal pain
b. Cholelithiasis
c. Exploratory laparoscopy
d. Ruptured appendix - CORRECT ANSWER-A. Abdominal Pain
For further explanation look at page 160.
Mrs. Smith's admitting data indicates that her birthdate is 3-21-1948. On the
discharge summary, Mrs. Smith's birthdate is recorded as 7-21-1948. Which quality
element is missing from Mrs. Smith's health record?
a. Data completeness
b. Data consistency
c. Data accessibility
d. Data comprehensiveness - CORRECT ANSWER-B. Data Quality
For Further explanation see page 160.
Data that have been grouped together into meaningful categories according to a
classification system are referred to as ___________ data.
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
, a. Research
b. Reference
c. Coded
d. Demographic - CORRECT ANSWER-C. Coded Data
For further explanation see page 160.
Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians
about proper documentation in the health record. Which of the following would
she NOT instruct them to do?
a. Obliterate errors
b. Leave existing entries intact
c. Label late entries as being late
d. Ensure the legal signature of an individual making a correction accompanies the
correction. - CORRECT ANSWER-A. Obliterate Errors
For further explanation see page 160.
All documentation entered in the medical record relating to the patient's diagnosis
and treatment are considered this type of data:
a. Clinical
b. Identification
c. Secondary
Exam Questions and Answers 100%
Pass
Mildred Smith was admitted to a nursing facility with the following information:
"Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis
her medical information was listed along with a summary of the care already
provided. This information is documented on the:
a.) Admitting physical evaluation record
b.) Patient's rights acknowledgement form
c.) Release of Information form
d.) Transfer Record - CORRECT ANSWER-D. Transfer Record
For further explanation look at page 160
A 65 y/o white male was admitted to the hospital on a 1/15 complaining of
abdominal pain. The attending physician requested an upper GI series and a
laboratory evaluation of CBC and UA. The X-ray revealed possible cholelithiasis
and the UA showed an increase in white blood cell count. The patient was taken to
,surgery for an exploratory laparoscopy and a ruptured appendix was discovered.
The chief complaint was:
a. Abdominal pain
b. Cholelithiasis
c. Exploratory laparoscopy
d. Ruptured appendix - CORRECT ANSWER-A. Abdominal Pain
For further explanation look at page 160.
Mrs. Smith's admitting data indicates that her birthdate is 3-21-1948. On the
discharge summary, Mrs. Smith's birthdate is recorded as 7-21-1948. Which quality
element is missing from Mrs. Smith's health record?
a. Data completeness
b. Data consistency
c. Data accessibility
d. Data comprehensiveness - CORRECT ANSWER-B. Data Quality
For Further explanation see page 160.
Data that have been grouped together into meaningful categories according to a
classification system are referred to as ___________ data.
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
, a. Research
b. Reference
c. Coded
d. Demographic - CORRECT ANSWER-C. Coded Data
For further explanation see page 160.
Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians
about proper documentation in the health record. Which of the following would
she NOT instruct them to do?
a. Obliterate errors
b. Leave existing entries intact
c. Label late entries as being late
d. Ensure the legal signature of an individual making a correction accompanies the
correction. - CORRECT ANSWER-A. Obliterate Errors
For further explanation see page 160.
All documentation entered in the medical record relating to the patient's diagnosis
and treatment are considered this type of data:
a. Clinical
b. Identification
c. Secondary
