RHIT exam prep Questions with complete
solutions 2024
Example jof jPoint-of-Service jcare j& jdocumentation j- jANS✓✓-RN jusing ja
jterminal jto jrecord jvital jsigns. jThere's ja jdifference jbetween jcomputer
japplication jin jhealth jcare jand jclinical japplication jof jcomputers
What jdo jI jfind jin jMedical jStaff jRules j& jRegulations? j- jANS✓✓-Doc
jrequirements jfor jpts' jrecords, jtime jframe jfor jcompletion jof jMRs, jpenalties jfor
jfailure jto jcomply jC jthese jrequirements
Auto jauthentication. jWhy jdoesn't jTJC japprove jit? j- jANS✓✓-No jguarantee jthat
jMD jactually jreviewed jthe jMR j& jdid jsign jit jelectronically. jSome jfacilities jdo juse
jauto jathentication
In jwhat jsetting jInterdisciplinary jplan jof jcare jis jused? j- jANS✓✓-LTC
TJC jcompliance jrate jfor jDelinquent jrecords jis j- jANS✓✓-Under j50%
Who jis jresponsible jfor jaccurateness j& jcompleteness jof jpts jMRs? j- jANS✓✓-
MDs j(not jHIM jdirector, jRNs jor jother jadministrative jpositions)
Dictated jOperative jreport jis jdue j- jANS✓✓-Immediately jafter jsurgery. jIf
jtranscription jservice jis jdown, jthe jsurgeon jhas jto jwrite ja jdetailed jOP jnote
One jof jUtilization jReview jfunctions j- jANS✓✓-Compare jseverity jof jillness j&
jIntensity jof jservice jwarrant jacute jcare jlevel
One jof jClinical jCare jEval jprocesses j- jANS✓✓-Quality jof jfollow-up jcare
Tumor jregistry jcases jaccession jnumbers j- jANS✓✓-Each jcase jin jTumor
jregistry jis jassigned ja junique jaccession jnumber. jEx: j10-001 j(10- jyear jthe jcase
jwas jentered jin ja jdatabase, j001 j- jcase j#1)
What jis jaccession jregister? j- jANS✓✓-Permanent jlog jof jall jcases jentered jin ja
jdatabase j(used jin jTumor jregistry)
,What jis jR-ADT jsystem? j- jANS✓✓-Registration-Admission, jDC j& jTransfer
jsystem. jBest jto juse jfor jtracking jpts jwho jhave jbeen jtransferred jto ja jspecialty
junit
Difference jbetween jROS j& jH&P j- jANS✓✓-1) jReview jof jSystems j- jrecord jof
jsubjective jSx jthat ja jpt jmay jhave jforgotten jto jmention
2) jH&P j- jrecord jof jObjective jSx jMD jis jobserving j& jother jinfo j(social jHx, jHx jof
jpresent jillness)
Recommendation jfor jimprovement jfrom jTJC j- jANS✓✓-# jof jdelinquent jrecords
jis j>50% jAND jDelinquent jrecords jmissing jH&P j>2% jof jthe jAverage jmonthly
jDCs
Integrated jvs jSeparated jProgress jnotes j- jANS✓✓-Integrated j- jall jproviders
jfrom jevery jdiscipline jrecord jprogress jnotes jsequentially jon jthe jsame jform
vs
Separated j- jevery jdiscipline jhas jits jown jdesignated jform jto jrecord jtheir
jProgress jnotes
LTC jpt jcare jplans jrely jon jdocumentation jfound jin j- jANS✓✓-1) jInterdisciplinary
jpt jcare jplan
2) jDC jsummary
3) jTransfer jrecords
Ambulatory jcare jproviders jrely jon jdocumentation jfound jin j- jANS✓✓-Problem
jlist
Core jmeasures jquality jindicators jfor jcompliance jwith jHCQIP j(Medicare jHealth
jCare jQuality jImprovement jProgram) j- jANS✓✓-MI j- jpt jis jDC'd jon jASA, jbeta
jblockers jor jother jheart jRxs
Stroke j- jpt jis jDC'd jon jan janti-thrombotic
Pneumonia j- jpt jhad jblood jculture jbefore j1st jAbx jstarted
Regional jhealth jinformation jorganizations j- jANS✓✓-Support jhealth jinformation
jexchange jwithin ja jgeographic jregion
One jessential jitem jon jPhysical jexam j- jANS✓✓-General jappearance jas
jassessed jby jMD j(Chief jcomplaint, jROS j& jFamily jHx j- jmedical jHx jprovided jby
jthe jpt)
Elements jof jwhich jdata jset jdo jI jcollect jif jI'm ja jtrauma jregistrar? j- jANS✓✓-
DEEDs j(Data jElements jfor jEDs) j- jrecommended jdata jset jfor jhospital-based jEDs
,Data jset jfor jAcute jCare jhospitals j- jANS✓✓-UHDDS j(Uniform jHospital jData jSet)
j- jrequired jdata jset jfor jAcute jCare jhospitals
Data jset jfor jLTC j- jANS✓✓-MDS j(Minimum jData jSet) j- jrequired jdata jset jfor
jLTCs
ORYX j- jANS✓✓-An jinitiative jof jTJC jthat jimplements j5 jcore jmeasures jto
jimprove jsafety jand jquality jof jhealth jcare.
5 jcore jmeasures jof jORYX j- jANS✓✓-CHF. jAMI. jPneumonia j(CAP). jEach jhas
jrequirements, je.g. jASA jat jarrival j& jDC, jbeta-blockers, jblood jculture, jsmoking
jcessation jadvice, jetc. jORYX jhas jmore jcore jmeasure jsets. jA jhospital jchooses
jthe jset jaccording jto jthe jtype jof jpts jit jtreats j(can jbe jone jcore j& jrest jnon-core)
Quantitative jvs jQualitative janalysis jof jMRs j- jANS✓✓-Quantitative j- jcheck
jpresence jor jabsence jof jnecessary jsigs, jreports
vs
Qualitative j- jcheck jdocumentation jconsistency, je.g. jcompare jpt's jRx jprofile jto
jMAR. jQuality jof jdocumentation jNOT jclinical jcare
Index jwith jUnique jIdentifier jcodes j- jANS✓✓-Physician jindex j- jnot jreal jMDs
jname, jbut jcodes. jTo jprotect jMDs jidentity
POMR j- jANS✓✓-Problem jOriented jMR. jHelps jindex jdocumentation jthroughout
jMR
H&P jtime jstandard jto jmeet jTJC j& jCoP jrequirements j- jANS✓✓-24 jhrs jafter
jadmission jor jprior jto jsurgery
DC jsummary jrecords j- jANS✓✓-Significant jfindings jduring jhospitalization
Time jframe jand jcopies jof jrecent jH&P jper jTJC j- jANS✓✓-Copies jof jrecent jH&P
jdone jin jMD's joffice jis jallowed jin jlieu jof jadmission jH&P jas jlong jas jthe jinterval
jnote j(interval jchanges) jare jpresent jupon jadmission
When jcan jInterval jnote jreplace jH&P jupon jadmission? j- jANS✓✓-1) jIf jpt jis jre-
admitted jwithin j30 jdays jfor jthe jsame jproblem j& jcopy jof jrecent jH&P jis
javailable;
2) jIf jcopy jof jrecent jH&P jdone jin jMD's joffice jis javailable jupon jadmission
Indices jin jhospital j- jANS✓✓-1) jMPI j- jcross-reference jof jpt's jname j& jMR
jnumber;
2) jDisease jindex j- ja jlisting jin jdiagnostic jcode jnumber jorder j(I jcan juse jit jto jget
jstats jon j# jof ja jDz jcases);
3) jPhysician jindex j- ja jlisting jof jcases jin jorder jby jMD's jname jor jnumber;
, 4) jOperation jindex j- ja jlisting jof joperations jperformed
Most jserious jdelinquencies j- jANS✓✓-1) jH&P;
2) jOperative jreport;
Formal jrelease jof jpt jfrom jhospital jis j- jANS✓✓-DC jorder. jIf jDC jorder jis
jmissing j- jpt jis jassumed jto jleave jAMA
Who jcan jaccept jVOs? j- jANS✓✓-Persons jdesignated jby jhospital's jP&Ps jand
jState j& jFederal jlaws
When jis jproblem jlist jrequired? j- jANS✓✓-On j3rd jvisit
RHIO j- jANS✓✓-Regional jHealth jInformation jOrganization j- jnetwork jallowing
jproviders jto jaccess jpts jMRs
Info jon jMR jsupplied jby ja jpt j- jANS✓✓-Health jHx, jCC j& jROS j- jall jsubjective
Data jcomprehensiveness j- jANS✓✓-Presence jof jall jrequired jdata jelements
CARF j- jANS✓✓-Commission jon jAccreditation jof jRehab jFacilities
Pt jcertification jperiod jin jHome jHealth j- jANS✓✓-60 jdays. jCertification jperiod jis
ja jsummary jon jeach jpt
Data jreliability j- jANS✓✓-Data jare jconsistent jno jmatter jhow jmany jtimes jthe
jsame jdata jare jcollected j& jentered jinto ja jsystem
Final jProgress jNote jcan jsubstitute jfor ja jDC jsummary j- jANS✓✓-1) jPts jin
jhospital jfor j<40 jhrs jC jminor jproblem;
2) jNormal jNBs;
3) jUncomplicated jOB jdeliveries
Authors jin jMR jshould jbe jID's jby j- jANS✓✓-Biometrics, je.g. jJoe jSmith, jRN.
jOther jtypes j(sig, jinitials) jmust jbe juniquely jidentifiable
RAI jcomponents jin jLTC jfacilities j- jANS✓✓-Resident jAssessment jInstrument:
j1) jAssessment;
2) jUtilization jguideline;
3) jMDS j(min jdata jset)
Who jeducates jMDs jabout jclinical jdocumentation? j- jANS✓✓-HIM j(HI jManager)
When jdoes jH&P jhave jto jbe jdone jon jsurgical jpts jper jTJC? j- jANS✓✓-Prior jto
jsurgery
solutions 2024
Example jof jPoint-of-Service jcare j& jdocumentation j- jANS✓✓-RN jusing ja
jterminal jto jrecord jvital jsigns. jThere's ja jdifference jbetween jcomputer
japplication jin jhealth jcare jand jclinical japplication jof jcomputers
What jdo jI jfind jin jMedical jStaff jRules j& jRegulations? j- jANS✓✓-Doc
jrequirements jfor jpts' jrecords, jtime jframe jfor jcompletion jof jMRs, jpenalties jfor
jfailure jto jcomply jC jthese jrequirements
Auto jauthentication. jWhy jdoesn't jTJC japprove jit? j- jANS✓✓-No jguarantee jthat
jMD jactually jreviewed jthe jMR j& jdid jsign jit jelectronically. jSome jfacilities jdo juse
jauto jathentication
In jwhat jsetting jInterdisciplinary jplan jof jcare jis jused? j- jANS✓✓-LTC
TJC jcompliance jrate jfor jDelinquent jrecords jis j- jANS✓✓-Under j50%
Who jis jresponsible jfor jaccurateness j& jcompleteness jof jpts jMRs? j- jANS✓✓-
MDs j(not jHIM jdirector, jRNs jor jother jadministrative jpositions)
Dictated jOperative jreport jis jdue j- jANS✓✓-Immediately jafter jsurgery. jIf
jtranscription jservice jis jdown, jthe jsurgeon jhas jto jwrite ja jdetailed jOP jnote
One jof jUtilization jReview jfunctions j- jANS✓✓-Compare jseverity jof jillness j&
jIntensity jof jservice jwarrant jacute jcare jlevel
One jof jClinical jCare jEval jprocesses j- jANS✓✓-Quality jof jfollow-up jcare
Tumor jregistry jcases jaccession jnumbers j- jANS✓✓-Each jcase jin jTumor
jregistry jis jassigned ja junique jaccession jnumber. jEx: j10-001 j(10- jyear jthe jcase
jwas jentered jin ja jdatabase, j001 j- jcase j#1)
What jis jaccession jregister? j- jANS✓✓-Permanent jlog jof jall jcases jentered jin ja
jdatabase j(used jin jTumor jregistry)
,What jis jR-ADT jsystem? j- jANS✓✓-Registration-Admission, jDC j& jTransfer
jsystem. jBest jto juse jfor jtracking jpts jwho jhave jbeen jtransferred jto ja jspecialty
junit
Difference jbetween jROS j& jH&P j- jANS✓✓-1) jReview jof jSystems j- jrecord jof
jsubjective jSx jthat ja jpt jmay jhave jforgotten jto jmention
2) jH&P j- jrecord jof jObjective jSx jMD jis jobserving j& jother jinfo j(social jHx, jHx jof
jpresent jillness)
Recommendation jfor jimprovement jfrom jTJC j- jANS✓✓-# jof jdelinquent jrecords
jis j>50% jAND jDelinquent jrecords jmissing jH&P j>2% jof jthe jAverage jmonthly
jDCs
Integrated jvs jSeparated jProgress jnotes j- jANS✓✓-Integrated j- jall jproviders
jfrom jevery jdiscipline jrecord jprogress jnotes jsequentially jon jthe jsame jform
vs
Separated j- jevery jdiscipline jhas jits jown jdesignated jform jto jrecord jtheir
jProgress jnotes
LTC jpt jcare jplans jrely jon jdocumentation jfound jin j- jANS✓✓-1) jInterdisciplinary
jpt jcare jplan
2) jDC jsummary
3) jTransfer jrecords
Ambulatory jcare jproviders jrely jon jdocumentation jfound jin j- jANS✓✓-Problem
jlist
Core jmeasures jquality jindicators jfor jcompliance jwith jHCQIP j(Medicare jHealth
jCare jQuality jImprovement jProgram) j- jANS✓✓-MI j- jpt jis jDC'd jon jASA, jbeta
jblockers jor jother jheart jRxs
Stroke j- jpt jis jDC'd jon jan janti-thrombotic
Pneumonia j- jpt jhad jblood jculture jbefore j1st jAbx jstarted
Regional jhealth jinformation jorganizations j- jANS✓✓-Support jhealth jinformation
jexchange jwithin ja jgeographic jregion
One jessential jitem jon jPhysical jexam j- jANS✓✓-General jappearance jas
jassessed jby jMD j(Chief jcomplaint, jROS j& jFamily jHx j- jmedical jHx jprovided jby
jthe jpt)
Elements jof jwhich jdata jset jdo jI jcollect jif jI'm ja jtrauma jregistrar? j- jANS✓✓-
DEEDs j(Data jElements jfor jEDs) j- jrecommended jdata jset jfor jhospital-based jEDs
,Data jset jfor jAcute jCare jhospitals j- jANS✓✓-UHDDS j(Uniform jHospital jData jSet)
j- jrequired jdata jset jfor jAcute jCare jhospitals
Data jset jfor jLTC j- jANS✓✓-MDS j(Minimum jData jSet) j- jrequired jdata jset jfor
jLTCs
ORYX j- jANS✓✓-An jinitiative jof jTJC jthat jimplements j5 jcore jmeasures jto
jimprove jsafety jand jquality jof jhealth jcare.
5 jcore jmeasures jof jORYX j- jANS✓✓-CHF. jAMI. jPneumonia j(CAP). jEach jhas
jrequirements, je.g. jASA jat jarrival j& jDC, jbeta-blockers, jblood jculture, jsmoking
jcessation jadvice, jetc. jORYX jhas jmore jcore jmeasure jsets. jA jhospital jchooses
jthe jset jaccording jto jthe jtype jof jpts jit jtreats j(can jbe jone jcore j& jrest jnon-core)
Quantitative jvs jQualitative janalysis jof jMRs j- jANS✓✓-Quantitative j- jcheck
jpresence jor jabsence jof jnecessary jsigs, jreports
vs
Qualitative j- jcheck jdocumentation jconsistency, je.g. jcompare jpt's jRx jprofile jto
jMAR. jQuality jof jdocumentation jNOT jclinical jcare
Index jwith jUnique jIdentifier jcodes j- jANS✓✓-Physician jindex j- jnot jreal jMDs
jname, jbut jcodes. jTo jprotect jMDs jidentity
POMR j- jANS✓✓-Problem jOriented jMR. jHelps jindex jdocumentation jthroughout
jMR
H&P jtime jstandard jto jmeet jTJC j& jCoP jrequirements j- jANS✓✓-24 jhrs jafter
jadmission jor jprior jto jsurgery
DC jsummary jrecords j- jANS✓✓-Significant jfindings jduring jhospitalization
Time jframe jand jcopies jof jrecent jH&P jper jTJC j- jANS✓✓-Copies jof jrecent jH&P
jdone jin jMD's joffice jis jallowed jin jlieu jof jadmission jH&P jas jlong jas jthe jinterval
jnote j(interval jchanges) jare jpresent jupon jadmission
When jcan jInterval jnote jreplace jH&P jupon jadmission? j- jANS✓✓-1) jIf jpt jis jre-
admitted jwithin j30 jdays jfor jthe jsame jproblem j& jcopy jof jrecent jH&P jis
javailable;
2) jIf jcopy jof jrecent jH&P jdone jin jMD's joffice jis javailable jupon jadmission
Indices jin jhospital j- jANS✓✓-1) jMPI j- jcross-reference jof jpt's jname j& jMR
jnumber;
2) jDisease jindex j- ja jlisting jin jdiagnostic jcode jnumber jorder j(I jcan juse jit jto jget
jstats jon j# jof ja jDz jcases);
3) jPhysician jindex j- ja jlisting jof jcases jin jorder jby jMD's jname jor jnumber;
, 4) jOperation jindex j- ja jlisting jof joperations jperformed
Most jserious jdelinquencies j- jANS✓✓-1) jH&P;
2) jOperative jreport;
Formal jrelease jof jpt jfrom jhospital jis j- jANS✓✓-DC jorder. jIf jDC jorder jis
jmissing j- jpt jis jassumed jto jleave jAMA
Who jcan jaccept jVOs? j- jANS✓✓-Persons jdesignated jby jhospital's jP&Ps jand
jState j& jFederal jlaws
When jis jproblem jlist jrequired? j- jANS✓✓-On j3rd jvisit
RHIO j- jANS✓✓-Regional jHealth jInformation jOrganization j- jnetwork jallowing
jproviders jto jaccess jpts jMRs
Info jon jMR jsupplied jby ja jpt j- jANS✓✓-Health jHx, jCC j& jROS j- jall jsubjective
Data jcomprehensiveness j- jANS✓✓-Presence jof jall jrequired jdata jelements
CARF j- jANS✓✓-Commission jon jAccreditation jof jRehab jFacilities
Pt jcertification jperiod jin jHome jHealth j- jANS✓✓-60 jdays. jCertification jperiod jis
ja jsummary jon jeach jpt
Data jreliability j- jANS✓✓-Data jare jconsistent jno jmatter jhow jmany jtimes jthe
jsame jdata jare jcollected j& jentered jinto ja jsystem
Final jProgress jNote jcan jsubstitute jfor ja jDC jsummary j- jANS✓✓-1) jPts jin
jhospital jfor j<40 jhrs jC jminor jproblem;
2) jNormal jNBs;
3) jUncomplicated jOB jdeliveries
Authors jin jMR jshould jbe jID's jby j- jANS✓✓-Biometrics, je.g. jJoe jSmith, jRN.
jOther jtypes j(sig, jinitials) jmust jbe juniquely jidentifiable
RAI jcomponents jin jLTC jfacilities j- jANS✓✓-Resident jAssessment jInstrument:
j1) jAssessment;
2) jUtilization jguideline;
3) jMDS j(min jdata jset)
Who jeducates jMDs jabout jclinical jdocumentation? j- jANS✓✓-HIM j(HI jManager)
When jdoes jH&P jhave jto jbe jdone jon jsurgical jpts jper jTJC? j- jANS✓✓-Prior jto
jsurgery
