RHIT Exam Review: Questions & Answers
The Medical Record Committee is assessing various strategies to improve documentation in the health
record. Concerns have been raised that current documentation practices may be insufficient to support
diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be
the best first step to help improve physician documentation? - ANSWER:Determine the type and volume
of documentation problems
This type of healthcare organization review is conducted at the request of the healthcare facility seeking
accreditation. - ANSWER:Voluntary review
Healthcare facilities must have processes in place to maintain and correct the master patient index (MPI)
against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Which of the
following is used to match patients so that patient information can be merged? - ANSWER:Algorithm
A hospital interested in finding out if a physician has any adverse licensure actions should review data
from: - ANSWER:NPDB (National Practitioner Data Bank)
was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical
malpractice payments, adverse licensure actions, and certain professional review actions (such as denial
of medical staff privileges) taken by healthcare entities such as hospitals against physicians, dentists, and
other healthcare providers as well as private accrediting organizations and peer review organizations
(Sharp 2016, 185). - ANSWER:NPDB (National Practitioner Data Bank)
Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list? - ANSWER:It
applies to orders and medication-related documentation
The HIM professional is arguing against the use of the copy/paste function in the EHR. Which of the
following would be the position for this argument? - ANSWER:I am unable to identify the author.
A quantitative review of the health record for missing reports and signatures that occurs when the
patient is in the hospital is referred to as a - ANSWER:concurrent review
When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is
determined by - ANSWER:Clinical privileges
Which database must a healthcare facility query as part of the credentialing process when a physician
initially applies for medical staff privileges? - ANSWER:NPDB (National Practitioner Data Bank)
The process in which a healthcare organization addresses the provider documentation issues that are
conflicting, ambiguous, or incomplete is called - ANSWER:Querying
In determining the data collection requirements for Medicare and Medicaid patients in a long-term care
facility, the health information technician would consult standards from - ANSWER:CMS (Centers for
Medicare and Medicaid Services)
Where in an acute care health record would the documentation "Admit to 3C. Diet: NPO. Meds:
Compazine 10mg IV Q 6 PRN." be found? - ANSWER:Physician Orders
, Information collected in a cancer registry typically includes: - ANSWER:Type and stage of cancer and
patient demographic information
Which of the following is a key feature of a problem-oriented health record? - ANSWER:Itemized list of
patient's present and past conditions
Which of the following is the key to the identification and access of a patient's health record? -
ANSWER:Master Patient Index (MPI)
In performing quantitative analysis of an emergency room health record, which of the following data
elements would the health information technician look for to be present in the record? -
ANSWER:Patient identification, time and means of patient arrival, pertinent history of illness
When managing the master patient index (MPI) which of the following would be the biggest concern for
the health information technician? - ANSWER:Duplicate health record numbers
Where would you expect to find the following documentation in the health record: "BUN 14, Creatinine
0.9, H&H 8.8 and 25.4?" - ANSWER:laboratory report
Reviewing a health record for missing signatures and medical reports is called - ANSWER:analysis
Patient history questionnaires, problem lists, diagnostic test results, and immunization records are
commonly found in which type of record? - ANSWER:ambulatory record
Which of the following electronic record technological capabilities would allow paper-based health
records to be incorporated into a patient's EHR? - ANSWER:Documentation-imaging technology
Deficiencies in a health record include which of the following? - ANSWER:Missing document
The overall goal of documentation standards is to: - ANSWER:Ensure what is documented in the health
record is complete and accurately reflects the treatment provided to the patient.
Why is only the most current version of a document displayed? - ANSWER:To ensure there is no
confusion on the correct document
This concept includes the process of data governance, patient identification, authorization validation,
amendments and record corrections, and audit validation. - ANSWER:Data integrity
What concept refers to the process of creating management and oversight of data assets to support the
organization's mission, vision, and values? - ANSWER:Information Governance
___________________________ are the information collected within a healthcare organization during
the normal day-to-day operations that support patient care and business operations. -
ANSWER:Information assets
What is the term that describes the data that defines and characterizes other data within an electronic
system? - ANSWER:Metadata
Safeguards established to support the data being available when and where is it needed under the data
quality model is called: - ANSWER:Accessibility
The Medical Record Committee is assessing various strategies to improve documentation in the health
record. Concerns have been raised that current documentation practices may be insufficient to support
diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be
the best first step to help improve physician documentation? - ANSWER:Determine the type and volume
of documentation problems
This type of healthcare organization review is conducted at the request of the healthcare facility seeking
accreditation. - ANSWER:Voluntary review
Healthcare facilities must have processes in place to maintain and correct the master patient index (MPI)
against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Which of the
following is used to match patients so that patient information can be merged? - ANSWER:Algorithm
A hospital interested in finding out if a physician has any adverse licensure actions should review data
from: - ANSWER:NPDB (National Practitioner Data Bank)
was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical
malpractice payments, adverse licensure actions, and certain professional review actions (such as denial
of medical staff privileges) taken by healthcare entities such as hospitals against physicians, dentists, and
other healthcare providers as well as private accrediting organizations and peer review organizations
(Sharp 2016, 185). - ANSWER:NPDB (National Practitioner Data Bank)
Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list? - ANSWER:It
applies to orders and medication-related documentation
The HIM professional is arguing against the use of the copy/paste function in the EHR. Which of the
following would be the position for this argument? - ANSWER:I am unable to identify the author.
A quantitative review of the health record for missing reports and signatures that occurs when the
patient is in the hospital is referred to as a - ANSWER:concurrent review
When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is
determined by - ANSWER:Clinical privileges
Which database must a healthcare facility query as part of the credentialing process when a physician
initially applies for medical staff privileges? - ANSWER:NPDB (National Practitioner Data Bank)
The process in which a healthcare organization addresses the provider documentation issues that are
conflicting, ambiguous, or incomplete is called - ANSWER:Querying
In determining the data collection requirements for Medicare and Medicaid patients in a long-term care
facility, the health information technician would consult standards from - ANSWER:CMS (Centers for
Medicare and Medicaid Services)
Where in an acute care health record would the documentation "Admit to 3C. Diet: NPO. Meds:
Compazine 10mg IV Q 6 PRN." be found? - ANSWER:Physician Orders
, Information collected in a cancer registry typically includes: - ANSWER:Type and stage of cancer and
patient demographic information
Which of the following is a key feature of a problem-oriented health record? - ANSWER:Itemized list of
patient's present and past conditions
Which of the following is the key to the identification and access of a patient's health record? -
ANSWER:Master Patient Index (MPI)
In performing quantitative analysis of an emergency room health record, which of the following data
elements would the health information technician look for to be present in the record? -
ANSWER:Patient identification, time and means of patient arrival, pertinent history of illness
When managing the master patient index (MPI) which of the following would be the biggest concern for
the health information technician? - ANSWER:Duplicate health record numbers
Where would you expect to find the following documentation in the health record: "BUN 14, Creatinine
0.9, H&H 8.8 and 25.4?" - ANSWER:laboratory report
Reviewing a health record for missing signatures and medical reports is called - ANSWER:analysis
Patient history questionnaires, problem lists, diagnostic test results, and immunization records are
commonly found in which type of record? - ANSWER:ambulatory record
Which of the following electronic record technological capabilities would allow paper-based health
records to be incorporated into a patient's EHR? - ANSWER:Documentation-imaging technology
Deficiencies in a health record include which of the following? - ANSWER:Missing document
The overall goal of documentation standards is to: - ANSWER:Ensure what is documented in the health
record is complete and accurately reflects the treatment provided to the patient.
Why is only the most current version of a document displayed? - ANSWER:To ensure there is no
confusion on the correct document
This concept includes the process of data governance, patient identification, authorization validation,
amendments and record corrections, and audit validation. - ANSWER:Data integrity
What concept refers to the process of creating management and oversight of data assets to support the
organization's mission, vision, and values? - ANSWER:Information Governance
___________________________ are the information collected within a healthcare organization during
the normal day-to-day operations that support patient care and business operations. -
ANSWER:Information assets
What is the term that describes the data that defines and characterizes other data within an electronic
system? - ANSWER:Metadata
Safeguards established to support the data being available when and where is it needed under the data
quality model is called: - ANSWER:Accessibility
