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RHIA Tenth Edition Domain 1 Questions and Answers Updated 2026/2027 Version | Verified Answers

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RHIA Tenth Edition Domain 1 Questions and Answers Updated 2026/2027 Version | Verified Answers 1. A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? - ANSWER Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records 2. Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay? - ANSWER Uniform Ambulatory Care Data Set 3. The purpose of the data dictionary is to _________________ definitions and ensure consistency of use. - ANSWER Standardize 4. Keith is the supervisor of the MPI and chart deficiency review staff in the HIM department, which also includes being the liaison for the billing department and the R-ADT staff. He frequently meets with Michael, the R ADT supervisor, to discuss methods to combat healthcare fraud and the process of verifying that the patients are truly who they say they are and that these patients have the appropriate documentation for verification. This process is called ______. - ANSWER Identity matching 5. Records in disparate system that do not communicate or do not have a logical relationship for record management are called - ANSWER hybrid health records 6. The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risks to all stakeholders, and advance the public good is called - ANSWER information governance 7. Mary Smtih, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of patients to the acute-care hospital in which she works. What is the first resource she should use? - ANSWER UHDDS 8. In long-term care, the resident's comprehensive assessment is based on data collected in the - ANSWER MDS 9. Which of the following are considered dimensions of data quality? - ANSWER Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency 10. Which of the following is a retention concern with electronic health records? - ANSWER hardware obsolescence 11. The practices or methods that defend against charges questioning the integrity of the data and documents are called: - ANSWER Nonrepudiation 12. Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons - ANSWER physician 13. Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry? - ANSWER case finding 14. The medical staff at Regency Health is nationally renowned for its skill in performing cardiac procedures. The nursing staff in the cardiac unit has noticed that a significant number of health records do not have informed consents prior to the performance of procedures. Obtaining informed consent is the responsibility of the: - ANSWER Physician 15. Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to: - ANSWER Ask the chief of staff to complete them 16. The first deliverable from a legal health record (LHR) definition project is a: - ANSWER List of LHR stakeholders 17. The name of the government agency that has led the development of basic data sets for health records and computer databases is the: - ANSWER The National Committee on Vital and Health Statistics 18. Which of the following is a concept designed to help standardize clinical content for sharing between providers? - ANSWER Continuity of care record 19. A regular review of legal health record policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called a legal health record. - ANSWER maintenance plan 20. Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record? - ANSWER document name, media type, source system, electronic storage start date, stop printing start date. 21. Bob Jones is considering contractors for his company's medical benefits, and he is reviewing health plans from two different entities. Which of the following databases should he consult to compare the performance of the two health plans? - ANSWER HEDIS 22. Legally, which of the following is the most important in determining the length of time that a hospital must retain medical records? - ANSWER Statute of Limitation 23. Copies of personal health records (PHRs) are considered part of the legal health record when: - ANSWER Used by the healthcare entity to provide treatment 24. Which information system is the gateway into a healthcare facility to identify if a patient has been treated there, contains demographic information to confirm patient identity, and shows if the patient has been treated at other facilities within an integrated delivery system (IDS) - ANSWER EMPI 25. The device and media controls standard requires organizations to implement policies and procedures to - ANSWER Address the final disposition of ePHI, hardware, and electronic media

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RHIA Tenth Edition Domain 1 Questions
and Answers Updated 2026/2027 Version |
Verified Answers


1. A medical group practice has contracted with an HIM professional to help
define the practice's legal health record. Which of the following should the
HIM professional perform first to identify the components of the legal health
record? - ANSWER ✅ Develop a list of statutes, regulations, rules, and
guidelines that contain requirements affecting the release of health records


2. Which data set would be used to document an elective surgical procedure
that does not require an overnight hospital stay? - ANSWER ✅ Uniform
Ambulatory Care Data Set


3. The purpose of the data dictionary is to _________________ definitions and
ensure consistency of use. - ANSWER ✅ Standardize


4. Keith is the supervisor of the MPI and chart deficiency review staff in the
HIM department, which also includes being the liaison for the billing
department and the R-ADT staff. He frequently meets with Michael, the R-
ADT supervisor, to discuss methods to combat healthcare fraud and the
process of verifying that the patients are truly who they say they are and that
these patients have the appropriate documentation for verification. This
process is called ______. - ANSWER ✅ Identity matching


5. Records in disparate system that do not communicate or do not have a
logical relationship for record management are called - ANSWER ✅ hybrid
health records

, 6. The leadership and organizational structures, policies, procedures,
technology, and controls that ensure that patient and other enterprise data
and information sustain and extend the entity's mission and strategies,
deliver value, comply with laws and regulations, minimize risks to all
stakeholders, and advance the public good is called - ANSWER ✅
information governance


7. Mary Smtih, RHIA, has been charged with the responsibility of designing a
data collection form to be used on admission of patients to the acute-care
hospital in which she works. What is the first resource she should use? -
ANSWER ✅ UHDDS


8. In long-term care, the resident's comprehensive assessment is based on data
collected in the - ANSWER ✅ MDS


9. Which of the following are considered dimensions of data quality? -
ANSWER ✅ Relevancy, granularity, timeliness, currency, accuracy,
precision, and consistency


10.Which of the following is a retention concern with electronic health records?
- ANSWER ✅ hardware obsolescence


11.The practices or methods that defend against charges questioning the
integrity of the data and documents are called: - ANSWER ✅
Nonrepudiation


12.Which of the following indexes would be used to compare the number and
quality of treatments for patients who underwent the same operation with
different surgeons - ANSWER ✅ physician

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Subido en
21 de julio de 2026
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2025/2026
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