Mock RHIA Part 1 Exam Questions and
Complete Solutions Graded A+
Community Hospital is implementing a hybrid record. Some documentation will be paper-based and
digitally scanned after discharge. Other parts of the record will be totally electronic. The Medical Record
Committee is discussing how interim reports in the health record should be handled. Some on the
committee think that all interim reports should be discarded and only the final reports retained in the
scanned record. Others take the opposite position. Which of the following is a best practice that the
health information management (HIM) director should suggest to the committee? - Answer: Maintaining
all interim reports provides the greatest measure of security.
Maintaining all interim reports provides the greatest measure of security. Managing health information
in a hybrid record environment is challenging, but by maintaining the reports the facility will reduce
some potential problems.
The four major issues that have an impact on the record retention policy of a healthcare facility are
patient care, research, space, and: - Answer: Legal and statutory requirements
Hospitals and other healthcare facilities develop health record retention policies to ensure that health
records comply with all applicable state and federal regulations and accreditation standards.
Highland Hospital requires all dates be recorded in its clinical information system as MM/DD/YYYY. This
required data definition and format should be part of the________. - Answer: data dictionary
A data dictionary is like a map of the database. Whenever a set of data is created, it should have an
accompanying data dictionary. A data dictionary can ensure consistency by standardizing definitions. A
typical data dictionary allows for the format of each attribute such as MM/DD/YYYY for the date.
Facility-based cancer registries receive approval as part of the facility cancer program from which of the
following agencies? - Answer: American College of Surgeons
The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer
programs. One of the requirements of this process is the existence of a cancer registry as part of the
,program. When the ACS surveys the cancer program, part of the survey process is a review of cancer
registry activities.
When an Entity Relationship Diagram (ERD) is implemented as a relational database, an attribute will
become a(n): - Answer: field
Attributes are the characteristics or data elements to be collected about each entity. They can be
depicted in an ERD as oval shapes coming off an entity. Attributes become the fields or column headings
within the data tables of a relational database.
A database rule that states "patient gender must be recorded as M=male, F=female, and U= unknown" is
referred to as: - Answer: Application control
Databases contain rules known as application controls that must be satisfied by the stored data. Data
integrity happens when all of the data in the database conform to all rules. Certain fields, such as dates,
must be entered in a certain format, such as MM/DD/YYYY. Application controls such as edit checks help
ensure that the originally-entered data and changes to these data follow certain rules.
Which of the following clinicians would use the DSM-V system to assist with establishing a diagnosis? -
Answer: Practicing psychiatrists
DSM-V is a multiaxial coding system with five axes. Axis I includes the mental disorders or illnesses
comparable to general medical illnesses. Axis II includes personality disorders. Axis III includes general
medical illnesses. Axis IV covers life events or social problems that affect the patient. Axis V is the overall
level of the patient's functioning, usually as determined by the Global Assessment of Functioning (GAF).
The American Psychiatric Association (APA) states two general uses for DSM: as a source of diagnostic
information that enhances clinical practice, research, and education.
What data set provides the underpinning of the home health prospective payment system (HH PPS)? -
Answer: OASIS
The HHPPS is based on a predetermined rate for a 60-day episode of home health care. OASIS data are
essential to home health agency's reimbursement under the HHPPS. OASIS data drive the determination
of the case-based adjustment. There are three components in the structure of payment under the
HHPPS: the national standardized episode rate, the HHA case-mix group, and adjustments.
, The primary purpose of a Minimum Data Set in healthcare is to: - Answer: Recommend common data
elements to be collected in health records
The need for standardized data definitions was recognized in the 1960s, and the National Committee on
Vital and Health Statistics took the lead developing uniform Minimum Data Sets for various sites of care.
As technology has driven the development of the data or information systems, the early data sets have
been supplemented with healthcare information standards that focus on EHR systems. A number of
standards-setting organizations are involved in developing uniform definitions, data fields, and views for
health record content and structure.
All states have a health department with a division 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 public health department must be notified. Which of the following diseases would be
reportable to the public health department? - Answer: Hepatitis B
Hepatitis B is caused by the hepatitis B virus and is considered a communicable disease that is
reportable to the public health department. This reporting process may be in writing, by telephone, or
by total number of cases.
A medical staff committee wants to compare long-term survival rates for breast cancer by comparing
outcomes for the mastectomy versus lumpectomy approaches. The best source of this information is
the: - Answer: Cancer registry
A cancer registry collects demographic information (such as name, health record number, address), type
and site of the cancer, diagnostic methodologies, treatment methodologies, and stage at the time of
diagnosis as well as periodically collects follow-up information on the patient's survival status.
Medicare requires that a history and physical examination be completed within what time frame after a
patient's admission to a hospital? - Answer: 24 hours
CMS requires that the history and physical examination be completed no more than 30 days before or
24 hours after admission and the report must be placed in the record within 24 hours after admission.
Complete Solutions Graded A+
Community Hospital is implementing a hybrid record. Some documentation will be paper-based and
digitally scanned after discharge. Other parts of the record will be totally electronic. The Medical Record
Committee is discussing how interim reports in the health record should be handled. Some on the
committee think that all interim reports should be discarded and only the final reports retained in the
scanned record. Others take the opposite position. Which of the following is a best practice that the
health information management (HIM) director should suggest to the committee? - Answer: Maintaining
all interim reports provides the greatest measure of security.
Maintaining all interim reports provides the greatest measure of security. Managing health information
in a hybrid record environment is challenging, but by maintaining the reports the facility will reduce
some potential problems.
The four major issues that have an impact on the record retention policy of a healthcare facility are
patient care, research, space, and: - Answer: Legal and statutory requirements
Hospitals and other healthcare facilities develop health record retention policies to ensure that health
records comply with all applicable state and federal regulations and accreditation standards.
Highland Hospital requires all dates be recorded in its clinical information system as MM/DD/YYYY. This
required data definition and format should be part of the________. - Answer: data dictionary
A data dictionary is like a map of the database. Whenever a set of data is created, it should have an
accompanying data dictionary. A data dictionary can ensure consistency by standardizing definitions. A
typical data dictionary allows for the format of each attribute such as MM/DD/YYYY for the date.
Facility-based cancer registries receive approval as part of the facility cancer program from which of the
following agencies? - Answer: American College of Surgeons
The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer
programs. One of the requirements of this process is the existence of a cancer registry as part of the
,program. When the ACS surveys the cancer program, part of the survey process is a review of cancer
registry activities.
When an Entity Relationship Diagram (ERD) is implemented as a relational database, an attribute will
become a(n): - Answer: field
Attributes are the characteristics or data elements to be collected about each entity. They can be
depicted in an ERD as oval shapes coming off an entity. Attributes become the fields or column headings
within the data tables of a relational database.
A database rule that states "patient gender must be recorded as M=male, F=female, and U= unknown" is
referred to as: - Answer: Application control
Databases contain rules known as application controls that must be satisfied by the stored data. Data
integrity happens when all of the data in the database conform to all rules. Certain fields, such as dates,
must be entered in a certain format, such as MM/DD/YYYY. Application controls such as edit checks help
ensure that the originally-entered data and changes to these data follow certain rules.
Which of the following clinicians would use the DSM-V system to assist with establishing a diagnosis? -
Answer: Practicing psychiatrists
DSM-V is a multiaxial coding system with five axes. Axis I includes the mental disorders or illnesses
comparable to general medical illnesses. Axis II includes personality disorders. Axis III includes general
medical illnesses. Axis IV covers life events or social problems that affect the patient. Axis V is the overall
level of the patient's functioning, usually as determined by the Global Assessment of Functioning (GAF).
The American Psychiatric Association (APA) states two general uses for DSM: as a source of diagnostic
information that enhances clinical practice, research, and education.
What data set provides the underpinning of the home health prospective payment system (HH PPS)? -
Answer: OASIS
The HHPPS is based on a predetermined rate for a 60-day episode of home health care. OASIS data are
essential to home health agency's reimbursement under the HHPPS. OASIS data drive the determination
of the case-based adjustment. There are three components in the structure of payment under the
HHPPS: the national standardized episode rate, the HHA case-mix group, and adjustments.
, The primary purpose of a Minimum Data Set in healthcare is to: - Answer: Recommend common data
elements to be collected in health records
The need for standardized data definitions was recognized in the 1960s, and the National Committee on
Vital and Health Statistics took the lead developing uniform Minimum Data Sets for various sites of care.
As technology has driven the development of the data or information systems, the early data sets have
been supplemented with healthcare information standards that focus on EHR systems. A number of
standards-setting organizations are involved in developing uniform definitions, data fields, and views for
health record content and structure.
All states have a health department with a division 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 public health department must be notified. Which of the following diseases would be
reportable to the public health department? - Answer: Hepatitis B
Hepatitis B is caused by the hepatitis B virus and is considered a communicable disease that is
reportable to the public health department. This reporting process may be in writing, by telephone, or
by total number of cases.
A medical staff committee wants to compare long-term survival rates for breast cancer by comparing
outcomes for the mastectomy versus lumpectomy approaches. The best source of this information is
the: - Answer: Cancer registry
A cancer registry collects demographic information (such as name, health record number, address), type
and site of the cancer, diagnostic methodologies, treatment methodologies, and stage at the time of
diagnosis as well as periodically collects follow-up information on the patient's survival status.
Medicare requires that a history and physical examination be completed within what time frame after a
patient's admission to a hospital? - Answer: 24 hours
CMS requires that the history and physical examination be completed no more than 30 days before or
24 hours after admission and the report must be placed in the record within 24 hours after admission.
