RHIT EXAM HEALTH DATA CONTENT AND STANDARDS
2025| LATEST UPDATE | GRADED A+
1. In preparation for an EHR, you are conducting a total facility inventory of all
forms currently used. You must name each form for bar coding and indexing
into a document management system. The unnamed document in front of
you includes a microscopic description of tissue excised during surgery. The
document type you are most likely to give to this form is ANS >> Pathology
report
2. Patient data collection requirements vary according to health care setting.
A data element you would expect to be collected in the MDS, but NOT in the
UHDDS would be ANS >> cognitive patterns
3. In the past, Joint Commission standards have focused on promoting the use
of a facility-approved abbreviation list to be used by hospital care providers.
With the advent of the Commission's national patient safety goals, the focus
has shifted to the ANS >> use of prohibited or "dangerous" abbreviations
4. Engaging patients and their families in health care decisions is one of the
core objectives for ANS >> achieving meaningful use of EHRs.
5. A risk manager needs to locate a full report of a patient's fall from his bed,
including witness reports and probable reasons for the fall. She would most
likely find this information in the ANS >> incident report
6. For continuity of care, ambulatory care providers are more likely than
providers of acute care services to rely on the documentation found in the-
ANS >> problem list
7. Joint Commission does not approved of auto authentication of entries in a
health record. The primary objection to this practice is that ANS >> evidence
cannot be provided that the physician actually reviewed and approved each
report.
https://www.stuvia.com/user/Mboffin 1/
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, 8. As part of a quality improvement study, you have been asked to provide
information on the menstrual history, number of pregnancies, and number of
living children on each OB patient from a stack of old obstetrical records. The
best place in the record to locate this information is the ANS >> prenatal record
9. As a concurrent record reviewer for an acute care facility, you have asked
Dr. Crossman to provide an updated history and physical for one of her recent
admission. Dr. Crossman pages through the medical record to a copy of an H &
P performed in her office a week before admission. You tell Dr. Crossman ANS
>> the H & P copy is acceptable as long as she documents any interval changes
10. You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's ANS >> disease index
11. Joint Commission requires the attending physician to countersign health
record documentation that is entered by ANS >> interns or medical students
12. The minimum length of time for retaining original medical records is
primarily governed by ANS >> state law
https://www.stuvia.com/user/Mboffin 2/
18
, 13. The use of personal signature stamps for authentication of entries in a
paper-based record requires special measures to guard against delegated
use of the stamp. In a completely computerized patient record system, similar
measures might be utilized to govern the use of ANS >> electronic signatures
14. Discharge summary documentation must include ANS >> significant findings
during hospitalization
15. The performance of qualitative analysis is an important tool in ensuring
data quality. These reviews evaluate ANS >> the overall quality of
documentation
16. Ultimate responsibility for the quality and completion of entries in patient
health records belongs to the ANS >> attending physician
17. The federally mandated resident assessment instrument used in long-term
care facilities consists of three basic components, including the new care area
assessment, utilization guidelines, and the ANS >> MDS
18. The foundation for communicating all patient care goals in long-term care
settings is the ANS >> interdisciplinary plan of care
19. As the Director of a Health Information Technology Program, your commu-
nity college has been selected to participate in the workforce development of
electronic health record specialists as outlined by ARRA and HITECH. In order
to keep abreast of changes in this program, you will need to regularly access
the Web site of this governmental agency ANS >> ONC
20. As part of Joint Commission's National Patient Safety Goal initiative, acute
care hospitals are now required to use a preoperative verification process to
confirm the patient's true identity, and to confirm that necessary documents
such as x-rays or medical records are available. They must also develop and
use a process for ANS >> marking the surgical site
21. In preparing your facility for initial accreditation by the Joint Commission,
you are trying to improve the process of ongoing record review. All health
record reviews are presently performed by a team of HIM department per-
https://www.stuvia.com/user/Mboffin 3/
18
2025| LATEST UPDATE | GRADED A+
1. In preparation for an EHR, you are conducting a total facility inventory of all
forms currently used. You must name each form for bar coding and indexing
into a document management system. The unnamed document in front of
you includes a microscopic description of tissue excised during surgery. The
document type you are most likely to give to this form is ANS >> Pathology
report
2. Patient data collection requirements vary according to health care setting.
A data element you would expect to be collected in the MDS, but NOT in the
UHDDS would be ANS >> cognitive patterns
3. In the past, Joint Commission standards have focused on promoting the use
of a facility-approved abbreviation list to be used by hospital care providers.
With the advent of the Commission's national patient safety goals, the focus
has shifted to the ANS >> use of prohibited or "dangerous" abbreviations
4. Engaging patients and their families in health care decisions is one of the
core objectives for ANS >> achieving meaningful use of EHRs.
5. A risk manager needs to locate a full report of a patient's fall from his bed,
including witness reports and probable reasons for the fall. She would most
likely find this information in the ANS >> incident report
6. For continuity of care, ambulatory care providers are more likely than
providers of acute care services to rely on the documentation found in the-
ANS >> problem list
7. Joint Commission does not approved of auto authentication of entries in a
health record. The primary objection to this practice is that ANS >> evidence
cannot be provided that the physician actually reviewed and approved each
report.
https://www.stuvia.com/user/Mboffin 1/
18
, 8. As part of a quality improvement study, you have been asked to provide
information on the menstrual history, number of pregnancies, and number of
living children on each OB patient from a stack of old obstetrical records. The
best place in the record to locate this information is the ANS >> prenatal record
9. As a concurrent record reviewer for an acute care facility, you have asked
Dr. Crossman to provide an updated history and physical for one of her recent
admission. Dr. Crossman pages through the medical record to a copy of an H &
P performed in her office a week before admission. You tell Dr. Crossman ANS
>> the H & P copy is acceptable as long as she documents any interval changes
10. You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's ANS >> disease index
11. Joint Commission requires the attending physician to countersign health
record documentation that is entered by ANS >> interns or medical students
12. The minimum length of time for retaining original medical records is
primarily governed by ANS >> state law
https://www.stuvia.com/user/Mboffin 2/
18
, 13. The use of personal signature stamps for authentication of entries in a
paper-based record requires special measures to guard against delegated
use of the stamp. In a completely computerized patient record system, similar
measures might be utilized to govern the use of ANS >> electronic signatures
14. Discharge summary documentation must include ANS >> significant findings
during hospitalization
15. The performance of qualitative analysis is an important tool in ensuring
data quality. These reviews evaluate ANS >> the overall quality of
documentation
16. Ultimate responsibility for the quality and completion of entries in patient
health records belongs to the ANS >> attending physician
17. The federally mandated resident assessment instrument used in long-term
care facilities consists of three basic components, including the new care area
assessment, utilization guidelines, and the ANS >> MDS
18. The foundation for communicating all patient care goals in long-term care
settings is the ANS >> interdisciplinary plan of care
19. As the Director of a Health Information Technology Program, your commu-
nity college has been selected to participate in the workforce development of
electronic health record specialists as outlined by ARRA and HITECH. In order
to keep abreast of changes in this program, you will need to regularly access
the Web site of this governmental agency ANS >> ONC
20. As part of Joint Commission's National Patient Safety Goal initiative, acute
care hospitals are now required to use a preoperative verification process to
confirm the patient's true identity, and to confirm that necessary documents
such as x-rays or medical records are available. They must also develop and
use a process for ANS >> marking the surgical site
21. In preparing your facility for initial accreditation by the Joint Commission,
you are trying to improve the process of ongoing record review. All health
record reviews are presently performed by a team of HIM department per-
https://www.stuvia.com/user/Mboffin 3/
18
