RHIT Exam Review Domain 1: Questions & Answers
In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about
each patient. The second is to:
a. Provide uniform data definitions
b. Guide connection between two systems
c. Guide access to data that exists in multiple databases
d. Provide a research database - ANSWER:a. Provide uniform data definitions
Healthcare data sets have two purposes. The first is to identify data elements that should be collected
for each patient. The second is to provide uniform definitions for common terms. The use of uniform
definitions ensures that data collected from a variety of healthcare settings will share a standard
definition. Standardizing data elements and definitions makes it possible to compare the data collected
at different facilities.
A health information technician is responsible for designing a data collection form to collect data on
patients in an acute-care hospital. The first resource that she should use is:
a. ORYX
b. UACDS
c. MDS
d. UHDDS - ANSWER:d. UHDDS
The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data
elements are collected from the health records of every hospital inpatient and later abstracted from the
health record and included in national databases.
To help support and manage data elements within an electronic health record (EHR), the organization
should implement a _______ to support standardized input and understanding of all data elements.
a. Data map
b. Core content
c. Clinical repository
d. Data dictionary - ANSWER:d. Data dictionary
,A data dictionary is a list of all the data elements within a specific information system that defines
individual data element, standard input of the data element, and specific data length. A data dictionary
should be implemented early by the organization to support standardization within the EHR.
Reviewing a health record for missing signatures and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing - ANSWER:a. Analysis
Analysis or review, of the health record is performed by HIM department personnel to determine the
completeness of the health record.
Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and
UACDS?
a. They define minimum data elements to be collected.
b. They provide a complete and exhaustive list of data elements that must be collected.
c. They provide a framework for data collection to which an individual facility can add data items
d. They vary by their purpose - ANSWER:b. They provide a complete and exhaustive list of data elements
that must be collected.
A data set is a list of recommended data elements with uniform definitions that are relevant for a
particular use. The contents of data sets vary by their purpose. However, data sets are not meant to limit
the number of data elements that can be collected. Most healthcare organizations collect additional data
elements that have meaning for their specific administrative and clinical operations. Standardizing data
elements and definitions makes it possible to compare the data collected at different facilities. A number
of data reporting requirements come from federal initiatives.
Ensuring data are not altered during transmission across a network or during storage is called:
a. Media control
b. Audit controls
c. Mitigation
d. Integrity - ANSWER:d. Integrity
Technology has advanced to a point at which an unauthorized user can capture data in transit and alter
it. Therefor, covered entities must confirm the integrity of data passed across a network. Integrity is the
, security principal that protects data from inappropriate modification or corruption. This includes both
unintentional and intentional modifications and destructions. Unintentional modifications and
destruction could occur if the wrong data are destroyed, the wrong backup is used to restore data or an
electrical fire destroys the computer.
The primary purpose of a data set in healthcare is to:
a. Recommend common data elements to be collected in health records.
b. Mandate all data that must be contained in a health record.
c. Define reportable data for federally funded programs.
d. Standardized medical vocabulary. - ANSWER:a. Recommend common data elements to be collected in
health records.
A data set is a recommended list of data elements that have defined and uniformed definitions that are
relevant for a particular use or are specific to a type of healthcare industry.
A notion for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin
reactions. She says she is following her diabetic diet." In which part of a problem-oriented health record
progress note would this be written?
a. Subjective
b. Objective
c. Assessment
d. Plan - ANSWER:a. Subjective
An audit of a hospitals electronic health system shows that diagnostic codes are not being reported at
the correct level of detail. This indicates a problem with data:
a. Consistency
b. Granularity
c. Comprehensiveness
d. Relevancy - ANSWER:b. Granularity
In which of the following examples does the gender of the patient constitute information rather than a
data element?
a. As an entry to be completed on the face sheet of the health record
b. In the note "50-year-old white male' in the patient history
c. In a study comparing the incidence of myocardial infarctions in black males as compared to white
females.
In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about
each patient. The second is to:
a. Provide uniform data definitions
b. Guide connection between two systems
c. Guide access to data that exists in multiple databases
d. Provide a research database - ANSWER:a. Provide uniform data definitions
Healthcare data sets have two purposes. The first is to identify data elements that should be collected
for each patient. The second is to provide uniform definitions for common terms. The use of uniform
definitions ensures that data collected from a variety of healthcare settings will share a standard
definition. Standardizing data elements and definitions makes it possible to compare the data collected
at different facilities.
A health information technician is responsible for designing a data collection form to collect data on
patients in an acute-care hospital. The first resource that she should use is:
a. ORYX
b. UACDS
c. MDS
d. UHDDS - ANSWER:d. UHDDS
The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data
elements are collected from the health records of every hospital inpatient and later abstracted from the
health record and included in national databases.
To help support and manage data elements within an electronic health record (EHR), the organization
should implement a _______ to support standardized input and understanding of all data elements.
a. Data map
b. Core content
c. Clinical repository
d. Data dictionary - ANSWER:d. Data dictionary
,A data dictionary is a list of all the data elements within a specific information system that defines
individual data element, standard input of the data element, and specific data length. A data dictionary
should be implemented early by the organization to support standardization within the EHR.
Reviewing a health record for missing signatures and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing - ANSWER:a. Analysis
Analysis or review, of the health record is performed by HIM department personnel to determine the
completeness of the health record.
Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and
UACDS?
a. They define minimum data elements to be collected.
b. They provide a complete and exhaustive list of data elements that must be collected.
c. They provide a framework for data collection to which an individual facility can add data items
d. They vary by their purpose - ANSWER:b. They provide a complete and exhaustive list of data elements
that must be collected.
A data set is a list of recommended data elements with uniform definitions that are relevant for a
particular use. The contents of data sets vary by their purpose. However, data sets are not meant to limit
the number of data elements that can be collected. Most healthcare organizations collect additional data
elements that have meaning for their specific administrative and clinical operations. Standardizing data
elements and definitions makes it possible to compare the data collected at different facilities. A number
of data reporting requirements come from federal initiatives.
Ensuring data are not altered during transmission across a network or during storage is called:
a. Media control
b. Audit controls
c. Mitigation
d. Integrity - ANSWER:d. Integrity
Technology has advanced to a point at which an unauthorized user can capture data in transit and alter
it. Therefor, covered entities must confirm the integrity of data passed across a network. Integrity is the
, security principal that protects data from inappropriate modification or corruption. This includes both
unintentional and intentional modifications and destructions. Unintentional modifications and
destruction could occur if the wrong data are destroyed, the wrong backup is used to restore data or an
electrical fire destroys the computer.
The primary purpose of a data set in healthcare is to:
a. Recommend common data elements to be collected in health records.
b. Mandate all data that must be contained in a health record.
c. Define reportable data for federally funded programs.
d. Standardized medical vocabulary. - ANSWER:a. Recommend common data elements to be collected in
health records.
A data set is a recommended list of data elements that have defined and uniformed definitions that are
relevant for a particular use or are specific to a type of healthcare industry.
A notion for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin
reactions. She says she is following her diabetic diet." In which part of a problem-oriented health record
progress note would this be written?
a. Subjective
b. Objective
c. Assessment
d. Plan - ANSWER:a. Subjective
An audit of a hospitals electronic health system shows that diagnostic codes are not being reported at
the correct level of detail. This indicates a problem with data:
a. Consistency
b. Granularity
c. Comprehensiveness
d. Relevancy - ANSWER:b. Granularity
In which of the following examples does the gender of the patient constitute information rather than a
data element?
a. As an entry to be completed on the face sheet of the health record
b. In the note "50-year-old white male' in the patient history
c. In a study comparing the incidence of myocardial infarctions in black males as compared to white
females.
