RHIA/RHIT Exam Study Guide – 2025–2026 Edition
Format: Questions | Bold Answers | Quick-Tip Notes
Section 1: Clinical Documentation & Coding (Q1–50)
1. Purpose of SNOMED CT
● Answer: Standardize clinical language for documentation
● Quick Tip: Think “universal clinical dictionary.”
2. Primary function of a Master Patient Index (MPI)
● Answer: Ensure unique patient identification and prevent duplicates
● Quick Tip: MPI = patient ID guardian.
3. Coding system for outpatient procedures
● Answer: CPT
● Quick Tip: CPT = outpatient billing code.
4. Coding system for inpatient procedures
● Answer: ICD-10-PCS
● Quick Tip: PCS = Procedures in the hospital.
5. Purpose of Clinical Documentation Improvement (CDI)
● Answer: Ensure documentation reflects patient diagnoses/procedures accurately for
coding, reimbursement, and quality reporting
● Quick Tip: CDI = Documentation accuracy booster.
6. Secondary use of health information
● Answer: Research, public health reporting, quality improvement
● Quick Tip: Not direct patient care.
7. Federal law protecting patient health information
● Answer: HIPAA
● Quick Tip: Think privacy + security.
, 8. Administrative safeguard under HIPAA
● Answer: Workforce training & access management
● Quick Tip: People + policy protections.
9. Physical safeguard under HIPAA
● Answer: Locked filing cabinets
● Quick Tip: Protect paper & physical environment.
10. Technical safeguard under HIPAA
● Answer: Encryption of electronic health information
● Quick Tip: Tech + security = digital shield.
11. Primary purpose of an EHR
● Answer: Improve accessibility, safety, and coordination of patient care
● Quick Tip: EHR = all-in-one patient record.
12. Main function of a Clinical Data Repository (CDR)
● Answer: Store and integrate patient data from multiple sources for reporting and
analysis
● Quick Tip: CDR = centralized data hub.
13. Key responsibility of Health Information Managers
● Answer: Oversee management, security, and quality of patient health information
● Quick Tip: HIM = guardian of health data.
14. Data stewardship definition
● Answer: Responsible management and protection of data throughout its lifecycle
● Quick Tip: Protect and manage data like a treasure.
15. Purpose of a Release of Information (ROI) form
● Answer: Authorize sharing of patient health information
● Quick Tip: ROI = legal OK to share info.
16. Clinical coding audits purpose
● Answer: Ensure coding accuracy for reimbursement, quality reporting, and compliance
● Quick Tip: Audit = check your coding work.
17. Key feature of electronic prescribing (eRx)
Format: Questions | Bold Answers | Quick-Tip Notes
Section 1: Clinical Documentation & Coding (Q1–50)
1. Purpose of SNOMED CT
● Answer: Standardize clinical language for documentation
● Quick Tip: Think “universal clinical dictionary.”
2. Primary function of a Master Patient Index (MPI)
● Answer: Ensure unique patient identification and prevent duplicates
● Quick Tip: MPI = patient ID guardian.
3. Coding system for outpatient procedures
● Answer: CPT
● Quick Tip: CPT = outpatient billing code.
4. Coding system for inpatient procedures
● Answer: ICD-10-PCS
● Quick Tip: PCS = Procedures in the hospital.
5. Purpose of Clinical Documentation Improvement (CDI)
● Answer: Ensure documentation reflects patient diagnoses/procedures accurately for
coding, reimbursement, and quality reporting
● Quick Tip: CDI = Documentation accuracy booster.
6. Secondary use of health information
● Answer: Research, public health reporting, quality improvement
● Quick Tip: Not direct patient care.
7. Federal law protecting patient health information
● Answer: HIPAA
● Quick Tip: Think privacy + security.
, 8. Administrative safeguard under HIPAA
● Answer: Workforce training & access management
● Quick Tip: People + policy protections.
9. Physical safeguard under HIPAA
● Answer: Locked filing cabinets
● Quick Tip: Protect paper & physical environment.
10. Technical safeguard under HIPAA
● Answer: Encryption of electronic health information
● Quick Tip: Tech + security = digital shield.
11. Primary purpose of an EHR
● Answer: Improve accessibility, safety, and coordination of patient care
● Quick Tip: EHR = all-in-one patient record.
12. Main function of a Clinical Data Repository (CDR)
● Answer: Store and integrate patient data from multiple sources for reporting and
analysis
● Quick Tip: CDR = centralized data hub.
13. Key responsibility of Health Information Managers
● Answer: Oversee management, security, and quality of patient health information
● Quick Tip: HIM = guardian of health data.
14. Data stewardship definition
● Answer: Responsible management and protection of data throughout its lifecycle
● Quick Tip: Protect and manage data like a treasure.
15. Purpose of a Release of Information (ROI) form
● Answer: Authorize sharing of patient health information
● Quick Tip: ROI = legal OK to share info.
16. Clinical coding audits purpose
● Answer: Ensure coding accuracy for reimbursement, quality reporting, and compliance
● Quick Tip: Audit = check your coding work.
17. Key feature of electronic prescribing (eRx)
