RHIT Exam Domain 1 Study Guide
A health record technician has been asked to review the discharge patient abstracting module of a
proposed new 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? - ANSWER:UHDDS
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: - ANSWER:Vocabulary standards
Patient care managers use the data documented in the health record to: - ANSWER:Evaluate patterns
and trends of patient care.
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: -
ANSWER:Data consistency
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? - ANSWER:Vital signs record
Which of the following is a key characteristic of the problem-oriented health record. - ANSWER:Uses an
itemized list of the patient's past and present health problems.
Which of the following is true regarding the reporting of communicable diseases? - ANSWER:The
diseases to be reported are established by state law.
A new HIM director has been asked by the hospital CIO to ensure data content standards are identified,
understood, implemented, and managed for the hospital's planned EHR system. Which of the following
should be the HIM director's first step in carrying out this responsibility? - ANSWER:Identify data content
requirements for all areas of the organization.
A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report? - ANSWER:Medication administration record and clinical laboratory reports.
Which of the following is considered the authoritative key in locating a health record? - ANSWER:Master
Patient Index
The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to
the proposed new codes for the next fiscal year and documenting variations in order to assess the
impact on the organization. This process creates a: - ANSWER:Data map
, A family practitioner requests the opinion of a physician specialist who reviews the patient's health
record and examines the patient. The physician specialist would record findings, impressions, and
recommendations in what type of report? - ANSWER:Consultation
The MPI manager has identified a pattern of duplicate health record numbers from the specimen
processing area of the hospital. After spending time merging the patient information and correcting the
duplicates in the patient information system, the MPI manager needs to notify which department to
correct the source system data? - ANSWER:Laboratory
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the
following data sets should the clinic consult to ensure that all the federally recommended data elements
for Medicare and Medicaid outpatients are collected by the system? - ANSWER:UACDS
To comply with the Joint Commission standards, the HIM director wants to be sure that 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? - ANSWER:Review each patient's health record concurrently to make sure that history and
physicals are present.
The HIM director is having difficulty with the emergency services on-call physicians completing their
health records. Three deficiency notices are sent to the physicians including an initial notice, a second
reminder, and a final notification. Which of the following would be the best first step in trying to rectify
the current situation? - ANSWER:Consult with the physician in charge of the on-call doctors for
suggestions on how to improve response to the current notices.
Valley High, a skilled nursing facility, wants to become certified to take part in federal government
reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to
become certified for these programs? - ANSWER:Conditions of Participation
A health record with deficiencies that is not completed within the timeframe specified in the medical
staff rules and regulations is called a(n): - ANSWER:Delinquent record
How do accreditation organizations such as the Joint Commission use the health record? - ANSWER:To
determine whether standards of care are being met.
Which of the following specialized patient assessment tools must be used by Medicare-certified home
care providers? - ANSWER:Outcomes and Assessment Information Set
Before healthcare organizations can provide services, they usually must obtain __ by government entities
such as the state or county in which they are located. - ANSWER:Licensure
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: -
ANSWER:The template was defined.
In designing an input screen for an EHR, which of the following would be best to capture discrete data? -
ANSWER:Drop-down menus
A health record technician has been asked to review the discharge patient abstracting module of a
proposed new 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? - ANSWER:UHDDS
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: - ANSWER:Vocabulary standards
Patient care managers use the data documented in the health record to: - ANSWER:Evaluate patterns
and trends of patient care.
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: -
ANSWER:Data consistency
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? - ANSWER:Vital signs record
Which of the following is a key characteristic of the problem-oriented health record. - ANSWER:Uses an
itemized list of the patient's past and present health problems.
Which of the following is true regarding the reporting of communicable diseases? - ANSWER:The
diseases to be reported are established by state law.
A new HIM director has been asked by the hospital CIO to ensure data content standards are identified,
understood, implemented, and managed for the hospital's planned EHR system. Which of the following
should be the HIM director's first step in carrying out this responsibility? - ANSWER:Identify data content
requirements for all areas of the organization.
A health data analyst has been asked to compile a report of the percentage of patients who had a
baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical
reports in the health record would the health data analyst need to consult in order to prepare this
report? - ANSWER:Medication administration record and clinical laboratory reports.
Which of the following is considered the authoritative key in locating a health record? - ANSWER:Master
Patient Index
The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to
the proposed new codes for the next fiscal year and documenting variations in order to assess the
impact on the organization. This process creates a: - ANSWER:Data map
, A family practitioner requests the opinion of a physician specialist who reviews the patient's health
record and examines the patient. The physician specialist would record findings, impressions, and
recommendations in what type of report? - ANSWER:Consultation
The MPI manager has identified a pattern of duplicate health record numbers from the specimen
processing area of the hospital. After spending time merging the patient information and correcting the
duplicates in the patient information system, the MPI manager needs to notify which department to
correct the source system data? - ANSWER:Laboratory
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the
following data sets should the clinic consult to ensure that all the federally recommended data elements
for Medicare and Medicaid outpatients are collected by the system? - ANSWER:UACDS
To comply with the Joint Commission standards, the HIM director wants to be sure that 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? - ANSWER:Review each patient's health record concurrently to make sure that history and
physicals are present.
The HIM director is having difficulty with the emergency services on-call physicians completing their
health records. Three deficiency notices are sent to the physicians including an initial notice, a second
reminder, and a final notification. Which of the following would be the best first step in trying to rectify
the current situation? - ANSWER:Consult with the physician in charge of the on-call doctors for
suggestions on how to improve response to the current notices.
Valley High, a skilled nursing facility, wants to become certified to take part in federal government
reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to
become certified for these programs? - ANSWER:Conditions of Participation
A health record with deficiencies that is not completed within the timeframe specified in the medical
staff rules and regulations is called a(n): - ANSWER:Delinquent record
How do accreditation organizations such as the Joint Commission use the health record? - ANSWER:To
determine whether standards of care are being met.
Which of the following specialized patient assessment tools must be used by Medicare-certified home
care providers? - ANSWER:Outcomes and Assessment Information Set
Before healthcare organizations can provide services, they usually must obtain __ by government entities
such as the state or county in which they are located. - ANSWER:Licensure
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: -
ANSWER:The template was defined.
In designing an input screen for an EHR, which of the following would be best to capture discrete data? -
ANSWER:Drop-down menus
