Rhit Exam with correct answers 100%
Which of the following is characteristic of the legal health record?
a. It must be electronic
b. It includes the designated record set
c. It is the record disclosed upon request
d. It includes a patient's personal health record - Correct Answers c. It is the record disclosed
upon request
What type of analysis compares omitted clinical information received from external providers
with the needed clinical information to make a correct diagnosis?
a. Risk management analysis
b. Qualitative analysis
c. Gap analysis
d. Document management analysis - Correct Answers c. Gap analysis
To comply with the Joint Commission standards, the HIM director wants to ensure the history
and physical examinations are documented in the patient's health record no later than 24 hours
after admission. Which of the following would be the best way to ensure the completeness of
the health record?
a. Establish a process to review health records immediately on discharge
b. Review each patient's health record concurrently to ensure the history and physicals are
present
c. Retrospectively review each patient's health record to ensure the history and physicals are
present
d. Write a memorandum to all physicians relating the Joint Commission requirements for
documenting history and physical examinations - Correct Answers b. Review each patient's
health record concurrently to ensure the history and physicals are present
,.An HIM technician was alerted by registration that the system has a record for John Smith with
two different birthdates. After an investigation the technician determined the documentation
was for two different patients, both named John Smith, who have the same health record
number in the EHR. This is an example of:
a. Overlap
b. Overlay
c. Duplicate
d. Purge - Correct Answers b. Overlay
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 - Correct Answers b.
Identify data content requirements for all areas of the organization
A health record with deficiencies that is not completed within the timeframe specified in the
medical staff rules and regulations is called a(n):
a. Suspended record
b. Delinquent record
c. Pending record
d. Illegal record - Correct Answers b. Delinquent record
A medical group practice has contracted with an HIM professional to help define the practice's
legal health record. Which of the following should the HIM professional perform first to identify
the components of the legal health record?
, a. Develop a list of all data elements referencing patients that are included in both paper and
electronic systems of the practice
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements
affecting the release of health records
c. Perform a quality check on all health record systems in the practice
d. Develop a listing and categorize all information requests for health information over the past
two years - Correct Answers b. Develop a list of statutes, regulations, rules, and guidelines that
contain requirements affecting the release of health records
Which of the following is the health record component that addresses the patient's current
complaints and symptoms and lists that patient's past medical, personal, and family conditions?
a. Problem list
b. Medical history
c. Physical examination
d. Clinical observation - Correct Answers b. Medical history
Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in
the health record. Which of the following is an example of improper teaching?
a. Obliterating or deleting errors
b. Leaving existing entries intact
c. Labeling late entries as being late
d. Ensuring the legal signature of an individual making a correction accompanies the correction -
Correct Answers a. Obliterating or deleting errors
The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15;
required field: yes; default value: none; template: none. For this data element, data integrity
would be better assured if:
a. The template was defined
Which of the following is characteristic of the legal health record?
a. It must be electronic
b. It includes the designated record set
c. It is the record disclosed upon request
d. It includes a patient's personal health record - Correct Answers c. It is the record disclosed
upon request
What type of analysis compares omitted clinical information received from external providers
with the needed clinical information to make a correct diagnosis?
a. Risk management analysis
b. Qualitative analysis
c. Gap analysis
d. Document management analysis - Correct Answers c. Gap analysis
To comply with the Joint Commission standards, the HIM director wants to ensure the history
and physical examinations are documented in the patient's health record no later than 24 hours
after admission. Which of the following would be the best way to ensure the completeness of
the health record?
a. Establish a process to review health records immediately on discharge
b. Review each patient's health record concurrently to ensure the history and physicals are
present
c. Retrospectively review each patient's health record to ensure the history and physicals are
present
d. Write a memorandum to all physicians relating the Joint Commission requirements for
documenting history and physical examinations - Correct Answers b. Review each patient's
health record concurrently to ensure the history and physicals are present
,.An HIM technician was alerted by registration that the system has a record for John Smith with
two different birthdates. After an investigation the technician determined the documentation
was for two different patients, both named John Smith, who have the same health record
number in the EHR. This is an example of:
a. Overlap
b. Overlay
c. Duplicate
d. Purge - Correct Answers b. Overlay
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 - Correct Answers b.
Identify data content requirements for all areas of the organization
A health record with deficiencies that is not completed within the timeframe specified in the
medical staff rules and regulations is called a(n):
a. Suspended record
b. Delinquent record
c. Pending record
d. Illegal record - Correct Answers b. Delinquent record
A medical group practice has contracted with an HIM professional to help define the practice's
legal health record. Which of the following should the HIM professional perform first to identify
the components of the legal health record?
, a. Develop a list of all data elements referencing patients that are included in both paper and
electronic systems of the practice
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements
affecting the release of health records
c. Perform a quality check on all health record systems in the practice
d. Develop a listing and categorize all information requests for health information over the past
two years - Correct Answers b. Develop a list of statutes, regulations, rules, and guidelines that
contain requirements affecting the release of health records
Which of the following is the health record component that addresses the patient's current
complaints and symptoms and lists that patient's past medical, personal, and family conditions?
a. Problem list
b. Medical history
c. Physical examination
d. Clinical observation - Correct Answers b. Medical history
Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in
the health record. Which of the following is an example of improper teaching?
a. Obliterating or deleting errors
b. Leaving existing entries intact
c. Labeling late entries as being late
d. Ensuring the legal signature of an individual making a correction accompanies the correction -
Correct Answers a. Obliterating or deleting errors
The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15;
required field: yes; default value: none; template: none. For this data element, data integrity
would be better assured if:
a. The template was defined
