RHIT Domain 1: Data Content, Structure &
Info Governance Exam Questions and
Answers
Question 1
Which of the following is considered a clinical documentation best practice?
a. Allowing clinicians to backdate physician orders
b. Restricting use of abbreviations to a list approved by hospital and medical staff
bylaws, rules, and regulations
c. Allowing clinicians to delete documentation errors in an electronic record
d. Prohibiting all verbal orders
Correct Answer
b
Clinical documentation best practices establish policies and guidelines that ensure
uniformity of both content and format of the patient record. One example of a
clinical documentation best practice would be to stipulate abbreviations and
symbols in the patient record to be permitted only when approved according to
hospital and medical staff bylaws, rules, and regulations (Johns 2015, 13).
Page 1 of 103
,Question 2
Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an EHR?
a. Make admission date a required field
b. Provide a template for entering data in the field
c. Make admission date a numeric field
d. Provide sufficient space for input of data
Correct Answer
b
Templates are a cross between free text and structured data entry. The user is able
to pick and choose data that are entered frequently, thus requiring the entry of data
that change from patient to patient. Templates can be customized to meet the
needs of the organization as data needs change by physician specialty, patient type
(surgical/medical/newborn), disease, and other classification of patients. In this
situation a template would provide structured data entry for the admission date
(Brinda 2016, 159-160).
Question 3
Patient care managers use the data documented in the health record to:
a. Determine the extent and effects of occupational hazards
b. Evaluate patterns and trends of patient care
c. Generate patient bills and third-party payer claims for reimbursement
d. Provide direct patient care
Correct Answer
b
Patient care managers are responsible for the overall evaluation of services
rendered for their particular area of responsibility. To identify patterns and trends,
they take details from individual health records and put all the information together
in one place (Sayles 2016b, 54).
Page 2 of 103
,Question 4
Which type of health record contains information about the means by which the
patient arrived at the healthcare setting and documentation of care provided to
stabilize the patient?
a. Ambulatory care
b. Emergency care
c. Long-term care
d. Rehabilitative care
Correct Answer
b
The emergency department record is a health record that is generated when a
patient visits an emergency department (ED) seeking treatment. Documentation in
the emergency department records includes the means by which the patient arrived
at the healthcare facility and documentation of care provided to stabilize the patient
(Brickner 2016, 100-101).
Question 5
Which of the following is a key characteristic of the problem-oriented health record?
a. Allows all providers to document in the health record
b. Uses laboratory reports and other diagnostic tools to determine health problems
c. Provides electronic documentation in the health record
d. Uses an itemized list of the patient's past and present health problems
Correct Answer
d
The problem-oriented health record is better suited to serve the patient and the
end user of the patient's information. The key characteristic of this format is an
itemized list of the patient's past and present social, psychological, and health
problems. Each problem is indexed with a unique number (Brickner 2016, 106).
Page 3 of 103
, Question 6
Which of the following is a true statement about the content of the legal health
record?
a. The legal health record contains only clinical data
b. The legal health record may contain metadata
c. The legal health record should not include e-mail
d. The legal health record should not include diagnostic images
Correct Answer
b
Organizations should develop and maintain an inventory of all documents and data
that could comprise the legal health record, considering all locations in the
organization (for example, separate departments or servers) where such information
could be housed. Organizations should also carefully consider whether to include
data such as pop-up reminders, alerts, and metadata. Metadata are data about data
and include information that track actions such as when and by whom a document
was accessed or changed (Rinehart-Thompson 2016a, 206).
Question 7
Community Hospital's HIM department conducted a random sample of 150 inpatient
health records to determine the discharge summary completion timeliness rate.
Thirteen discharged were determined to be out of compliance with completion
standards. Which of the following percentages represents the timeliness rate for
discharge summaries at Community Hospital?
a. 8.7%
b. 9.5%
c. 41.5%
d. 91.3%
Correct Answer
d
A discharge summary is a concise account of the patient's illness, course of
treatment, response to treatment, and condition at the time of patient discharge
from the hospital. Accreditation requirements state that the record needs to be
complete within 30 days of discharge. Hospitals set completion standards based on
this requirement. Record completion would include the discharge summary
(137/150) × 100 = 91.3% (Brickner 2016, 97).
Page 4 of 103
Info Governance Exam Questions and
Answers
Question 1
Which of the following is considered a clinical documentation best practice?
a. Allowing clinicians to backdate physician orders
b. Restricting use of abbreviations to a list approved by hospital and medical staff
bylaws, rules, and regulations
c. Allowing clinicians to delete documentation errors in an electronic record
d. Prohibiting all verbal orders
Correct Answer
b
Clinical documentation best practices establish policies and guidelines that ensure
uniformity of both content and format of the patient record. One example of a
clinical documentation best practice would be to stipulate abbreviations and
symbols in the patient record to be permitted only when approved according to
hospital and medical staff bylaws, rules, and regulations (Johns 2015, 13).
Page 1 of 103
,Question 2
Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an EHR?
a. Make admission date a required field
b. Provide a template for entering data in the field
c. Make admission date a numeric field
d. Provide sufficient space for input of data
Correct Answer
b
Templates are a cross between free text and structured data entry. The user is able
to pick and choose data that are entered frequently, thus requiring the entry of data
that change from patient to patient. Templates can be customized to meet the
needs of the organization as data needs change by physician specialty, patient type
(surgical/medical/newborn), disease, and other classification of patients. In this
situation a template would provide structured data entry for the admission date
(Brinda 2016, 159-160).
Question 3
Patient care managers use the data documented in the health record to:
a. Determine the extent and effects of occupational hazards
b. Evaluate patterns and trends of patient care
c. Generate patient bills and third-party payer claims for reimbursement
d. Provide direct patient care
Correct Answer
b
Patient care managers are responsible for the overall evaluation of services
rendered for their particular area of responsibility. To identify patterns and trends,
they take details from individual health records and put all the information together
in one place (Sayles 2016b, 54).
Page 2 of 103
,Question 4
Which type of health record contains information about the means by which the
patient arrived at the healthcare setting and documentation of care provided to
stabilize the patient?
a. Ambulatory care
b. Emergency care
c. Long-term care
d. Rehabilitative care
Correct Answer
b
The emergency department record is a health record that is generated when a
patient visits an emergency department (ED) seeking treatment. Documentation in
the emergency department records includes the means by which the patient arrived
at the healthcare facility and documentation of care provided to stabilize the patient
(Brickner 2016, 100-101).
Question 5
Which of the following is a key characteristic of the problem-oriented health record?
a. Allows all providers to document in the health record
b. Uses laboratory reports and other diagnostic tools to determine health problems
c. Provides electronic documentation in the health record
d. Uses an itemized list of the patient's past and present health problems
Correct Answer
d
The problem-oriented health record is better suited to serve the patient and the
end user of the patient's information. The key characteristic of this format is an
itemized list of the patient's past and present social, psychological, and health
problems. Each problem is indexed with a unique number (Brickner 2016, 106).
Page 3 of 103
, Question 6
Which of the following is a true statement about the content of the legal health
record?
a. The legal health record contains only clinical data
b. The legal health record may contain metadata
c. The legal health record should not include e-mail
d. The legal health record should not include diagnostic images
Correct Answer
b
Organizations should develop and maintain an inventory of all documents and data
that could comprise the legal health record, considering all locations in the
organization (for example, separate departments or servers) where such information
could be housed. Organizations should also carefully consider whether to include
data such as pop-up reminders, alerts, and metadata. Metadata are data about data
and include information that track actions such as when and by whom a document
was accessed or changed (Rinehart-Thompson 2016a, 206).
Question 7
Community Hospital's HIM department conducted a random sample of 150 inpatient
health records to determine the discharge summary completion timeliness rate.
Thirteen discharged were determined to be out of compliance with completion
standards. Which of the following percentages represents the timeliness rate for
discharge summaries at Community Hospital?
a. 8.7%
b. 9.5%
c. 41.5%
d. 91.3%
Correct Answer
d
A discharge summary is a concise account of the patient's illness, course of
treatment, response to treatment, and condition at the time of patient discharge
from the hospital. Accreditation requirements state that the record needs to be
complete within 30 days of discharge. Hospitals set completion standards based on
this requirement. Record completion would include the discharge summary
(137/150) × 100 = 91.3% (Brickner 2016, 97).
Page 4 of 103
