RHIT exam prep with correct answers
100% 2026
Example of Point-of-Service care & documentation - Correct Answers RN using a terminal to
record vital signs. There's a difference between computer application in health care and clinical
application of computers
What do I find in Medical Staff Rules & Regulations? - Correct Answers Doc requirements for pts'
records, time frame for completion of MRs, penalties for failure to comply C these requirements
Auto authentication. Why doesn't TJC approve it? - Correct Answers No guarantee that MD
actually reviewed the MR & did sign it electronically. Some facilities do use auto athentication
In what setting Interdisciplinary plan of care is used? - Correct Answers LTC
TJC compliance rate for Delinquent records is - Correct Answers Under 50%
Who is responsible for accurateness & completeness of pts MRs? - Correct Answers MDs (not
HIM director, RNs or other administrative positions)
Dictated Operative report is due - Correct Answers Immediately after surgery. If transcription
service is down, the surgeon has to write a detailed OP note
One of Utilization Review functions - Correct Answers Compare severity of illness & Intensity of
service warrant acute care level
One of Clinical Care Eval processes - Correct Answers Quality of follow-up care
,Tumor registry cases accession numbers - Correct Answers Each case in Tumor registry is
assigned a unique accession number. Ex: 10-001 (10- year the case was entered in a database,
001 - case #1)
What is accession register? - Correct Answers Permanent log of all cases entered in a database
(used in Tumor registry)
What is R-ADT system? - Correct Answers Registration-Admission, DC & Transfer system. Best to
use for tracking pts who have been transferred to a specialty unit
Difference between ROS & H&P - Correct Answers 1) Review of Systems - record of subjective Sx
that a pt may have forgotten to mention
2) H&P - record of Objective Sx MD is observing & other info (social Hx, Hx of present illness)
Recommendation for improvement from TJC - Correct Answers # of delinquent records is >50%
AND Delinquent records missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes - Correct Answers Integrated - all providers from every
discipline record progress notes sequentially on the same form
vs
Separated - every discipline has its own designated form to record their Progress notes
LTC pt care plans rely on documentation found in - Correct Answers 1) Interdisciplinary pt care
plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in - Correct Answers Problem list
,Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality
Improvement Program) - Correct Answers MI - pt is DC'd on ASA, beta blockers or other heart
Rxs
Stroke - pt is DC'd on an anti-thrombotic
Pneumonia - pt had blood culture before 1st Abx started
Regional health information organizations - Correct Answers Support health information
exchange within a geographic region
One essential item on Physical exam - Correct Answers General appearance as assessed by MD
(Chief complaint, ROS & Family Hx - medical Hx provided by the pt)
Elements of which data set do I collect if I'm a trauma registrar? - Correct Answers DEEDs (Data
Elements for EDs) - recommended data set for hospital-based EDs
Data set for Acute Care hospitals - Correct Answers UHDDS (Uniform Hospital Data Set) -
required data set for Acute Care hospitals
Data set for LTC - Correct Answers MDS (Minimum Data Set) - required data set for LTCs
ORYX - Correct Answers An initiative of TJC that implements 5 core measures to improve safety
and quality of health care.
5 core measures of ORYX - Correct Answers CHF. AMI. Pneumonia (CAP). Each has requirements,
e.g. ASA at arrival & DC, beta-blockers, blood culture, smoking cessation advice, etc. ORYX has
more core measure sets. A hospital chooses the set according to the type of pts it treats (can be
one core & rest non-core)
, Quantitative vs Qualitative analysis of MRs - Correct Answers Quantitative - check presence or
absence of necessary sigs, reports
vs
Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR. Quality of
documentation NOT clinical care
Index with Unique Identifier codes - Correct Answers Physician index - not real MDs name, but
codes. To protect MDs identity
POMR - Correct Answers Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements - Correct Answers 24 hrs after admission or
prior to surgery
DC summary records - Correct Answers Significant findings during hospitalization
Time frame and copies of recent H&P per TJC - Correct Answers Copies of recent H&P done in
MD's office is allowed in lieu of admission H&P as long as the interval note (interval changes)
are present upon admission
When can Interval note replace H&P upon admission? - Correct Answers 1) If pt is re-admitted
within 30 days for the same problem & copy of recent H&P is available;
2) If copy of recent H&P done in MD's office is available upon admission
Indices in hospital - Correct Answers 1) MPI - cross-reference of pt's name & MR number;
2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of a Dz
cases);
3) Physician index - a listing of cases in order by MD's name or number;
100% 2026
Example of Point-of-Service care & documentation - Correct Answers RN using a terminal to
record vital signs. There's a difference between computer application in health care and clinical
application of computers
What do I find in Medical Staff Rules & Regulations? - Correct Answers Doc requirements for pts'
records, time frame for completion of MRs, penalties for failure to comply C these requirements
Auto authentication. Why doesn't TJC approve it? - Correct Answers No guarantee that MD
actually reviewed the MR & did sign it electronically. Some facilities do use auto athentication
In what setting Interdisciplinary plan of care is used? - Correct Answers LTC
TJC compliance rate for Delinquent records is - Correct Answers Under 50%
Who is responsible for accurateness & completeness of pts MRs? - Correct Answers MDs (not
HIM director, RNs or other administrative positions)
Dictated Operative report is due - Correct Answers Immediately after surgery. If transcription
service is down, the surgeon has to write a detailed OP note
One of Utilization Review functions - Correct Answers Compare severity of illness & Intensity of
service warrant acute care level
One of Clinical Care Eval processes - Correct Answers Quality of follow-up care
,Tumor registry cases accession numbers - Correct Answers Each case in Tumor registry is
assigned a unique accession number. Ex: 10-001 (10- year the case was entered in a database,
001 - case #1)
What is accession register? - Correct Answers Permanent log of all cases entered in a database
(used in Tumor registry)
What is R-ADT system? - Correct Answers Registration-Admission, DC & Transfer system. Best to
use for tracking pts who have been transferred to a specialty unit
Difference between ROS & H&P - Correct Answers 1) Review of Systems - record of subjective Sx
that a pt may have forgotten to mention
2) H&P - record of Objective Sx MD is observing & other info (social Hx, Hx of present illness)
Recommendation for improvement from TJC - Correct Answers # of delinquent records is >50%
AND Delinquent records missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes - Correct Answers Integrated - all providers from every
discipline record progress notes sequentially on the same form
vs
Separated - every discipline has its own designated form to record their Progress notes
LTC pt care plans rely on documentation found in - Correct Answers 1) Interdisciplinary pt care
plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in - Correct Answers Problem list
,Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality
Improvement Program) - Correct Answers MI - pt is DC'd on ASA, beta blockers or other heart
Rxs
Stroke - pt is DC'd on an anti-thrombotic
Pneumonia - pt had blood culture before 1st Abx started
Regional health information organizations - Correct Answers Support health information
exchange within a geographic region
One essential item on Physical exam - Correct Answers General appearance as assessed by MD
(Chief complaint, ROS & Family Hx - medical Hx provided by the pt)
Elements of which data set do I collect if I'm a trauma registrar? - Correct Answers DEEDs (Data
Elements for EDs) - recommended data set for hospital-based EDs
Data set for Acute Care hospitals - Correct Answers UHDDS (Uniform Hospital Data Set) -
required data set for Acute Care hospitals
Data set for LTC - Correct Answers MDS (Minimum Data Set) - required data set for LTCs
ORYX - Correct Answers An initiative of TJC that implements 5 core measures to improve safety
and quality of health care.
5 core measures of ORYX - Correct Answers CHF. AMI. Pneumonia (CAP). Each has requirements,
e.g. ASA at arrival & DC, beta-blockers, blood culture, smoking cessation advice, etc. ORYX has
more core measure sets. A hospital chooses the set according to the type of pts it treats (can be
one core & rest non-core)
, Quantitative vs Qualitative analysis of MRs - Correct Answers Quantitative - check presence or
absence of necessary sigs, reports
vs
Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR. Quality of
documentation NOT clinical care
Index with Unique Identifier codes - Correct Answers Physician index - not real MDs name, but
codes. To protect MDs identity
POMR - Correct Answers Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements - Correct Answers 24 hrs after admission or
prior to surgery
DC summary records - Correct Answers Significant findings during hospitalization
Time frame and copies of recent H&P per TJC - Correct Answers Copies of recent H&P done in
MD's office is allowed in lieu of admission H&P as long as the interval note (interval changes)
are present upon admission
When can Interval note replace H&P upon admission? - Correct Answers 1) If pt is re-admitted
within 30 days for the same problem & copy of recent H&P is available;
2) If copy of recent H&P done in MD's office is available upon admission
Indices in hospital - Correct Answers 1) MPI - cross-reference of pt's name & MR number;
2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of a Dz
cases);
3) Physician index - a listing of cases in order by MD's name or number;
