RHIT EXAM: DOMAINS 1, 2, 3
QUESTIONS AND CORRECT
ANSWERS
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.
A crucial early step in designing an electronic health record (EHR) is to develop a(n) ________ in
which the characteristics of each data element are defined.
a. Accreditation manual
b. Core content
c. Continuity of care record
d. Data dictionary ✅✅CORRECT ANSW-d. Data dictionary
A data dictionary improves data validity and reliability within, across, and outside the enterprise
because it ensures that each piece of data can only mean one thing. A critical early step in
implementing the EHR is to develop a data dictionary.
long-term care, the resident's care plan is based on data collected in the:
a. UHDDS
b. OASIS-C
c. MDS
d. HEDIS ✅✅CORRECT ANSW-c. MDS
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 efforts toward computerization
c. Determine statistical formulas
,d. Provide a research database ✅✅CORRECT ANSW-a. Provide uniform data definitions
Healthcare data sets have two purposes. The first is to identify the 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 ✅✅CORRECT ANSW-d. UHDDS
The data collected by the Minimum Data Set (MDS) are used to develop care plans for residents and
to document placement at the appropriate level of care. The MDS provides a structured way to
organize resident information and develop a resident care plan
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. The federal government recommends, but does not mandate, implementation of most of the data
sets. ✅✅CORRECT ANSW-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 ✅✅CORRECT ANSW-d. Integrity
Technology has advanced to a point at which an unauthorized user can capture data in transit and
alter it. Therefore, CEs must confirm the integrity of data passed across a network. Integrity is the
security principle 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. Standardize medical vocabulary ✅✅CORRECT ANSW-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 notation 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 ✅✅CORRECT ANSW-a. Subjective
, Some providers also use a SOAP format for their problem-oriented progress notes. A subjective (S)
entry relates significant information in the patient's words or from the patient's point of view.
An audit of a hospital's 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 ✅✅CORRECT ANSW-b. Granularity
Data granularity requires that the attributes and values of data be defined at the correct level of
detail for the intended use of the data.
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
d. In a study of the age distribution of lung cancer patients ✅✅CORRECT ANSW-c. In a study
comparing the incidence of myocardial infarctions in black males as compared to white females
Data are the raw elements that make up our communications. Humans have the innate ability to
combine data they collect and, through all their senses, produce information (which is data that
have been combined to produce value) and enhance that information with experience and trial-and-
error that produces knowledge. In this example, the gender is tied to race in the data collection that
constitutes information and not a data element.
A core data set developed by ASTM to communicate a patient's past and current health information
as the patient transitions from one care setting to another is:
a. Ambulatory Care Data Set
b. Continuity of care record
QUESTIONS AND CORRECT
ANSWERS
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.
A crucial early step in designing an electronic health record (EHR) is to develop a(n) ________ in
which the characteristics of each data element are defined.
a. Accreditation manual
b. Core content
c. Continuity of care record
d. Data dictionary ✅✅CORRECT ANSW-d. Data dictionary
A data dictionary improves data validity and reliability within, across, and outside the enterprise
because it ensures that each piece of data can only mean one thing. A critical early step in
implementing the EHR is to develop a data dictionary.
long-term care, the resident's care plan is based on data collected in the:
a. UHDDS
b. OASIS-C
c. MDS
d. HEDIS ✅✅CORRECT ANSW-c. MDS
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 efforts toward computerization
c. Determine statistical formulas
,d. Provide a research database ✅✅CORRECT ANSW-a. Provide uniform data definitions
Healthcare data sets have two purposes. The first is to identify the 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 ✅✅CORRECT ANSW-d. UHDDS
The data collected by the Minimum Data Set (MDS) are used to develop care plans for residents and
to document placement at the appropriate level of care. The MDS provides a structured way to
organize resident information and develop a resident care plan
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. The federal government recommends, but does not mandate, implementation of most of the data
sets. ✅✅CORRECT ANSW-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 ✅✅CORRECT ANSW-d. Integrity
Technology has advanced to a point at which an unauthorized user can capture data in transit and
alter it. Therefore, CEs must confirm the integrity of data passed across a network. Integrity is the
security principle 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. Standardize medical vocabulary ✅✅CORRECT ANSW-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 notation 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 ✅✅CORRECT ANSW-a. Subjective
, Some providers also use a SOAP format for their problem-oriented progress notes. A subjective (S)
entry relates significant information in the patient's words or from the patient's point of view.
An audit of a hospital's 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 ✅✅CORRECT ANSW-b. Granularity
Data granularity requires that the attributes and values of data be defined at the correct level of
detail for the intended use of the data.
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
d. In a study of the age distribution of lung cancer patients ✅✅CORRECT ANSW-c. In a study
comparing the incidence of myocardial infarctions in black males as compared to white females
Data are the raw elements that make up our communications. Humans have the innate ability to
combine data they collect and, through all their senses, produce information (which is data that
have been combined to produce value) and enhance that information with experience and trial-and-
error that produces knowledge. In this example, the gender is tied to race in the data collection that
constitutes information and not a data element.
A core data set developed by ASTM to communicate a patient's past and current health information
as the patient transitions from one care setting to another is:
a. Ambulatory Care Data Set
b. Continuity of care record
