RHIT Exam Domain 1 Study Guide: Latest Updated : Guaranteed A+

A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? (Ans- UHDDS Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: (Ans- Vocabulary standards Patient care managers use the data documented in the health record to: (Ans- Evaluate patterns and trends of patient care. At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: (Ans- Data consistency A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? (Ans- Vital signs record Which of the following is a key characteristic of the problem-oriented health record. (Ans- Uses an itemized list of the patient's past and present health problems. Which of the following is true regarding the reporting of communicable diseases? (Ans- The diseases to be reported are established by state law. A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? (Ans- Identify data content requirements for all areas of the organization.