AHIMA Registered Health Information Technician
(RHIT) Certification Examination – Complete
Practice Questions and Detailed Answers
1. A health information technician is auditing medical records to ensure compliance with the
UHDDS. Which of the following is defined as the condition established after study to be
chiefly responsible for occasioning the admission of the patient to the hospital for care?
A. Complication
B. Primary diagnosis
C. Principal diagnosis
D. Admitting diagnosis
Correct Answer: C
Explanation: The Uniform Hospital Discharge Data Set (UHDDS) specifically defines the
principal diagnosis as the condition responsible for the admission after clinical study. This
definition is crucial for accurate DRG assignment and reimbursement in the inpatient
setting. Students often confuse ‘principal’ with ‘primary’ diagnosis, but ‘primary’ is a term
more frequently used in outpatient settings to denote the main reason for the encounter.
2. During a review of the Master Patient Index (MPI), an RHIT identifies that a single patient
has two different medical record numbers within the same facility. What is the correct term
for this occurrence?
A. Overlap
,B. Overlay
C. Duplicate
D. Integrity breach
Correct Answer: C
Explanation: A duplicate record occurs when one patient is assigned two or more medical
record numbers within a single facility. This differs from an ‘overlay,’ where two different
patients are assigned the same number, or an ‘overlap,’ where a patient has records at
different facilities within a system. Maintaining MPI integrity is vital for patient safety to
ensure all clinical information is accessible in one location.
3. A patient’s spouse requests access to the patient’s medical record while the patient is
hospitalized and incapacitated. The patient has not designated a healthcare proxy. According
to the HIPAA Privacy Rule, what should the HIM professional do?
A. Grant access immediately based on the spousal relationship.
B. Require a court order before releasing any information.
C. Deny all access until the patient can sign an authorization.
D. Release information only if the spouse is the legal personal representative.
Correct Answer: D
Explanation: Under HIPAA, a personal representative is a person who has the legal
authority to make healthcare decisions for an individual. While a spouse often holds this
, role, the HIM professional must verify legal status or follow state-specific ‘kinship’ laws for
incapacitated patients. Releasing information without proper authorization or legal
standing is a common compliance pitfall that leads to privacy breaches.
4. A hospital is transitioning from a paper-based system to an Electronic Health Record (EHR).
Which of the following is a primary benefit of using a data dictionary during this transition?
A. It provides a standardized definition for each data element.
B. It encrypts the data to prevent unauthorized access.
C. It automatically codes diagnoses from physician notes.
D. It serves as the physical storage location for the data.
Correct Answer: A
Explanation: A data dictionary is a central repository of information about data, such as
meaning, relationships to other data, origin, usage, and format. Its primary goal is to ensure
data consistency and integrity across different systems and users. Without a robust data
dictionary, organizations often struggle with data silos and conflicting interpretations of
clinical metrics.
5. An RHIT is calculating the hospital’s Case-Mix Index (CMI) for the month. Which data set is
required for this calculation?
A. MS-DRGs and their relative weights
B. CPT codes and the Medicare Physician Fee Schedule
C. ICD-10-CM codes and the total number of beds
(RHIT) Certification Examination – Complete
Practice Questions and Detailed Answers
1. A health information technician is auditing medical records to ensure compliance with the
UHDDS. Which of the following is defined as the condition established after study to be
chiefly responsible for occasioning the admission of the patient to the hospital for care?
A. Complication
B. Primary diagnosis
C. Principal diagnosis
D. Admitting diagnosis
Correct Answer: C
Explanation: The Uniform Hospital Discharge Data Set (UHDDS) specifically defines the
principal diagnosis as the condition responsible for the admission after clinical study. This
definition is crucial for accurate DRG assignment and reimbursement in the inpatient
setting. Students often confuse ‘principal’ with ‘primary’ diagnosis, but ‘primary’ is a term
more frequently used in outpatient settings to denote the main reason for the encounter.
2. During a review of the Master Patient Index (MPI), an RHIT identifies that a single patient
has two different medical record numbers within the same facility. What is the correct term
for this occurrence?
A. Overlap
,B. Overlay
C. Duplicate
D. Integrity breach
Correct Answer: C
Explanation: A duplicate record occurs when one patient is assigned two or more medical
record numbers within a single facility. This differs from an ‘overlay,’ where two different
patients are assigned the same number, or an ‘overlap,’ where a patient has records at
different facilities within a system. Maintaining MPI integrity is vital for patient safety to
ensure all clinical information is accessible in one location.
3. A patient’s spouse requests access to the patient’s medical record while the patient is
hospitalized and incapacitated. The patient has not designated a healthcare proxy. According
to the HIPAA Privacy Rule, what should the HIM professional do?
A. Grant access immediately based on the spousal relationship.
B. Require a court order before releasing any information.
C. Deny all access until the patient can sign an authorization.
D. Release information only if the spouse is the legal personal representative.
Correct Answer: D
Explanation: Under HIPAA, a personal representative is a person who has the legal
authority to make healthcare decisions for an individual. While a spouse often holds this
, role, the HIM professional must verify legal status or follow state-specific ‘kinship’ laws for
incapacitated patients. Releasing information without proper authorization or legal
standing is a common compliance pitfall that leads to privacy breaches.
4. A hospital is transitioning from a paper-based system to an Electronic Health Record (EHR).
Which of the following is a primary benefit of using a data dictionary during this transition?
A. It provides a standardized definition for each data element.
B. It encrypts the data to prevent unauthorized access.
C. It automatically codes diagnoses from physician notes.
D. It serves as the physical storage location for the data.
Correct Answer: A
Explanation: A data dictionary is a central repository of information about data, such as
meaning, relationships to other data, origin, usage, and format. Its primary goal is to ensure
data consistency and integrity across different systems and users. Without a robust data
dictionary, organizations often struggle with data silos and conflicting interpretations of
clinical metrics.
5. An RHIT is calculating the hospital’s Case-Mix Index (CMI) for the month. Which data set is
required for this calculation?
A. MS-DRGs and their relative weights
B. CPT codes and the Medicare Physician Fee Schedule
C. ICD-10-CM codes and the total number of beds
