RHIA Domain 1 Exam Questions and Answers New (2024/2025) Solved 100% Correct

Retention Program - ️️Inventory of records Format Location Preservation Period Provide information not easily determined from looking at records - ️️Secondary Data Sources Number assigned according to number of entry into a registry each year - ️️Accession Number Primary responsibility of coder - ️️Ensure quality of coded data Responsible for quality and completion of discharge summary - ️️Attending Physician Data set for px that does not require an overnight stay - ️️Uniform Ambulatory Care Data Set Records not completed within designated timeframe - ️️Delinquent Records Decision-making and authority over data-related matters - ️️Data Governance Includes information about trauma cases - ️️DEEDS Problem-oriented frameworks for assessment after problems have been identified - ️️Resident Assessment Protocols Snapshot of patient Disease processes Critical paths Clinical pathways - ️️Care Plan Dimensions of Data Quality - ️️Relevancy Granularity Timeliness Currency Accuracy Precision ConsistencyBarrier to computer-assisted coding - ️️Poor quality of documentation Graphical display of relationships between tables in a database - ️️ERD Accreditation and regulatory standards require a different record for each - ️️patient Component of Resident Assessment Instrument - ️️A standard minimum data set Documenting when and how a record was destroyed - ️️Certificate of Destruction Before list of elements to be returned from a SQL query - ️️SELECT Document imaging is part of... - ️️Record creation, capture, or receipt After ERD is implemented, an entity becomes... - ️️Table Most important aspect of determining record retention - ️️Statute of Limitations Record that follows a patient's care over time - ️️Longitudinal Record Data collected on large populations and stored in databases - ️️Aggregate Data Accessing and reviewing the work of colleagues in the same profession - ️️Peer Review Mandating display format (ex: xxx-xx-xxxx) - ️️Mask Contains diagnosis and summary of care already given - ️️Transfer Record Data related to a patient's diagnosis and treatment - ️️Clinical Discrepancies between two coders compromise - ️️Reliability Discharge summary must be completed within - ️️30 days Discharge summary for transfers must be completed within - ️️24 hours Discharge summaries are not requires for LOS less than - ️️48 hours Example of M:M relationship - ️️Patient to Consulting PhysiciansChief Complaint - ️️Reason for presentation Errors in medical record should not be - ️️Obliterated Coded - ️️Grouped into meaningful categories by classification system Principal Function of Health Records - ️️Repository of clinical documentation relevant to patient care Common form of problem-oriented format - ️️SOAP form of progress notes ER Record - ️️Time and means of arrival Treatment record Discharge instructions Who owns records? - ️️Healthcare org Abbreviations - ️️Should only have one meaning ICD-10-PCS Null Character - ️️Z Same order in any location - ️️Universal H&P Exam - ️️Must be placed in the record before a procedure is performed Occlusion - ️️Restricting blood flow Backlog in transcription - ️️Write a detailed note about procedure Provider examines patient at request of another provider - ️️Consultation Report In the absence of data dictionary - ️️Establish data dictionary policy with associated standards Destruction of Paper Records - ️️Shredding, Pulping, Pulverizing No degaussing No rounding up doses - ️️Precision Paper records do not have - ️️Built-in control mechanism No new H&P - ️️Readmitted within 30 days for same conditionPrincipal Procedure - ️️Definitive treatment of main condition Vocabulary Standards - ️️Standardizing medical terminology Analog Data - ️️Photographic, Film Autoauthentication - ️️Provider signs statement at all records are improved unless corrections made in time frame Not allowed HIM should check for record retention - ️️State and federal law