RHIT Exam Review Domain 1: Questions & Answers
A health record technician has been asked to review the discharge patient abstracting module of a
proposed new electronic health record (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?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS - ANSWER:d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on
every inpatient.
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:
a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards - ANSWER:d. Vocabulary standards
Vocabulary standards are a list or collection of clinical words or phrases with their meanings; also, the set
of words used by an individual or group within a particular subject field, such as to provide consistent
descriptions of medical terms for an individual's condition in the health record.
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 - ANSWER:b. Evaluate patterns and trends of patient care
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.
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:
a. Data comprehensiveness
b. Data consistency
c. Data currency
d. Data granularity - ANSWER:b. Data consistency
Consistency means ensuring the patient data is reliable and the same across the entire patient
encounter. In other words, patient data within the record should be the same and should not contradict
other data also in the patient record.
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?
a. Vital signs record
b. Initial nursing assessment record
c. Physician progress notes
d. Admission record - ANSWER:a. Vital signs record
The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse,
making it the best source to gather this type of information.
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 - ANSWER:d. Uses an itemized
list of the patient's past and present health problems
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.
Which of the following is true regarding the reporting of communicable diseases?
a. They must be reported by the patient to the health department.
b. The diseases to be reported are established by state law.
c. The diseases to be reported are established by HIPAA.
d. They are never reported because it would violate the patient's privacy. - ANSWER:b. The diseases to
be reported are established by state law.
All states have a health department with a division that is required to track and record communicable
diseases. When a patient is diagnosed with one of the diseases from the health department's
communicable disease list, the facility must notify the state public health department.
A new health information management (HIM) director has been asked by the hospital CIO to ensure data
content standards are identified, understood, implemented, and managed for the hospital's EHR system.
Which of the following should be the HIM director's first step in carrying out this responsibility?
a. Call the EHR vendor and ask to review the system's data dictionary
b. Identify data content requirements for all areas of the organization
c. Schedule a meeting with all department directors to get their input
d. Contact CMS to determine what data sets are required to be collected - ANSWER:b. Identify data
content requirements for all areas of the organization
Data content standards allow organizations to collect data once and use it many times in many ways.
They also assist in data storage and mining as well as sharing data with external organizations for use in
benchmarking and other purposes.
A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report?
A health record technician has been asked to review the discharge patient abstracting module of a
proposed new electronic health record (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?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS - ANSWER:d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on
every inpatient.
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:
a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards - ANSWER:d. Vocabulary standards
Vocabulary standards are a list or collection of clinical words or phrases with their meanings; also, the set
of words used by an individual or group within a particular subject field, such as to provide consistent
descriptions of medical terms for an individual's condition in the health record.
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 - ANSWER:b. Evaluate patterns and trends of patient care
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.
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:
a. Data comprehensiveness
b. Data consistency
c. Data currency
d. Data granularity - ANSWER:b. Data consistency
Consistency means ensuring the patient data is reliable and the same across the entire patient
encounter. In other words, patient data within the record should be the same and should not contradict
other data also in the patient record.
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?
a. Vital signs record
b. Initial nursing assessment record
c. Physician progress notes
d. Admission record - ANSWER:a. Vital signs record
The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse,
making it the best source to gather this type of information.
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 - ANSWER:d. Uses an itemized
list of the patient's past and present health problems
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.
Which of the following is true regarding the reporting of communicable diseases?
a. They must be reported by the patient to the health department.
b. The diseases to be reported are established by state law.
c. The diseases to be reported are established by HIPAA.
d. They are never reported because it would violate the patient's privacy. - ANSWER:b. The diseases to
be reported are established by state law.
All states have a health department with a division that is required to track and record communicable
diseases. When a patient is diagnosed with one of the diseases from the health department's
communicable disease list, the facility must notify the state public health department.
A new health information management (HIM) director has been asked by the hospital CIO to ensure data
content standards are identified, understood, implemented, and managed for the hospital's EHR system.
Which of the following should be the HIM director's first step in carrying out this responsibility?
a. Call the EHR vendor and ask to review the system's data dictionary
b. Identify data content requirements for all areas of the organization
c. Schedule a meeting with all department directors to get their input
d. Contact CMS to determine what data sets are required to be collected - ANSWER:b. Identify data
content requirements for all areas of the organization
Data content standards allow organizations to collect data once and use it many times in many ways.
They also assist in data storage and mining as well as sharing data with external organizations for use in
benchmarking and other purposes.
A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report?
