©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
RHIT Exam Review Domain 1 Questions and Answers (100% Pass)
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 - ✔️✔️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 - ✔️✔️d. Vocabulary standards
1
, ©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
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 - ✔️✔️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 - ✔️✔️b. Data consistency
2
, ©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
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 - ✔️✔️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 - ✔️✔️d.
Uses an itemized list of the patient's past and present health problems
3
, ©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
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. - ✔️✔️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
4
RHIT Exam Review Domain 1 Questions and Answers (100% Pass)
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 - ✔️✔️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 - ✔️✔️d. Vocabulary standards
1
, ©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
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 - ✔️✔️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 - ✔️✔️b. Data consistency
2
, ©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
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 - ✔️✔️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 - ✔️✔️d.
Uses an itemized list of the patient's past and present health problems
3
, ©PREP4EXAMS@2024[REAL EXAM DUMPS] Thursday, July 25, 2024 6:51 PM
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. - ✔️✔️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
4
