RHIA PRACTICE EXAM 1 NEWEST 2025 ACTUAL
EXAM COMPLETE REVISED QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+
/. Smith was admitted to a nursing facility with the following information: "patient is being
admitted for Organic brain syndrome." Underneath the diagnosis her medical
information was listed along with a summary of the care already provided. This
information is documented on the: - Answer-Transfer recrod
/.A 65-year-old white male was admitted to the hospital 1/15 complaining of abdominal
pain. The attending physician requested an upper GI series and laboratory eval of CBC
and UA. The x-ray revealed possible problems and the UA showed an increased white
blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a
ruptured appendix was discovered. The chief complaint was: - Answer-Abdominal pain
/.Smith's admitting data indicates that her birthdayis 5/21/14. On the discharge
summary, Smith's birth date is recorded as July 21. What quality element is missing
from Mrs. Smith's health record? - Answer-Data consistency
/.When defining the legal health record in a healthcare entity, it is best practice to
establish a policy statement of the legal health record as well as a: - Answer-Health
record matrix
/.Erin is the HIM director at anywhere hospital. She is teaching a class to clinicians
about proper documentation in the health record. what should she instruct them to do: -
Answer-Leave existing entries intact. Label late entries as being late. Ensure the legal
signature of an individual making a correction accompanies the correction.
/.All documentation entered in the medical record relating to the patient's diagnosis and
treatment are considered this type of data: - Answer-Clinical
/.Data that have been grouped into meaningful categories according to a classification
system are referred to as ________ data. - Answer-Coded
/.Conducting an inventory of the facility's records, determining the format and location of
record storage, assigning each record a time period for preservation and destroying
records that are no longer needed are all elements of a: - Answer-retention program
/.What is the principal function of health records? - Answer-Serve as the repository of
clinical documentation relevant to the care of individual patients
, /.The insured party's member identification number is an example of what type of data: -
Answer-financial data
/.What part of the problem-oriented medical record is used by many facilities that have
adopted the whole problem-oriented format? - Answer-The SOAP progress notes
/.What materials are required element in an emergency care record? - Answer-Time
and means of the patient's arrival, treatment rendered, and instructions at discharge
/.What type of information makes it easy for hospitals to compare and combine the
contents of multiple patient health record - Answer-uniform data set
/.What is a unique identifier in the relational database patient table - Answer-Patient
number
/.What is used by a long-term facility to gather information about specific health status
factors and includes information about specific risk factors in the resident's care? -
Answer-minimum data set
/.In a long-term care setting, these are problem-oriented frameworks for additional
patient assessment based on problem identification items: - Answer-Utilization
guidelines
/.Documenting the full depth and breadth of data use in a healthcare entitiy requires: -
Answer-Identifying the needs of data consumers
/.What is an example of a M-M relationship? - Answer-Patients to consulting physicians
/.What is a M-M relationship? - Answer-Many to many
/.Mrs. Smith was admitted to a hospital by Dr. Collins. Mrs. Smith's hospital bill was paid
by Blue Cross insurance. Upon discharge from the hospital, who owns the health record
of Mrs. Smith? - Answer-University Hospital
/.Decision making and authority over data-related matters is known as: - Answer-data
governance
/.Abbreviations can be a source of patient safety issues due to misinterpretation and
miscommunication. Abbreviations in the health record: - Answer-Should only have one
meaning
/.In ICD-10-PCS what value is used if there is a character that does not apply to a given
code? - Answer-Z
/.The primary responsibility of a coder is to: - Answer-ensure quality of coded data
EXAM COMPLETE REVISED QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+
/. Smith was admitted to a nursing facility with the following information: "patient is being
admitted for Organic brain syndrome." Underneath the diagnosis her medical
information was listed along with a summary of the care already provided. This
information is documented on the: - Answer-Transfer recrod
/.A 65-year-old white male was admitted to the hospital 1/15 complaining of abdominal
pain. The attending physician requested an upper GI series and laboratory eval of CBC
and UA. The x-ray revealed possible problems and the UA showed an increased white
blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a
ruptured appendix was discovered. The chief complaint was: - Answer-Abdominal pain
/.Smith's admitting data indicates that her birthdayis 5/21/14. On the discharge
summary, Smith's birth date is recorded as July 21. What quality element is missing
from Mrs. Smith's health record? - Answer-Data consistency
/.When defining the legal health record in a healthcare entity, it is best practice to
establish a policy statement of the legal health record as well as a: - Answer-Health
record matrix
/.Erin is the HIM director at anywhere hospital. She is teaching a class to clinicians
about proper documentation in the health record. what should she instruct them to do: -
Answer-Leave existing entries intact. Label late entries as being late. Ensure the legal
signature of an individual making a correction accompanies the correction.
/.All documentation entered in the medical record relating to the patient's diagnosis and
treatment are considered this type of data: - Answer-Clinical
/.Data that have been grouped into meaningful categories according to a classification
system are referred to as ________ data. - Answer-Coded
/.Conducting an inventory of the facility's records, determining the format and location of
record storage, assigning each record a time period for preservation and destroying
records that are no longer needed are all elements of a: - Answer-retention program
/.What is the principal function of health records? - Answer-Serve as the repository of
clinical documentation relevant to the care of individual patients
, /.The insured party's member identification number is an example of what type of data: -
Answer-financial data
/.What part of the problem-oriented medical record is used by many facilities that have
adopted the whole problem-oriented format? - Answer-The SOAP progress notes
/.What materials are required element in an emergency care record? - Answer-Time
and means of the patient's arrival, treatment rendered, and instructions at discharge
/.What type of information makes it easy for hospitals to compare and combine the
contents of multiple patient health record - Answer-uniform data set
/.What is a unique identifier in the relational database patient table - Answer-Patient
number
/.What is used by a long-term facility to gather information about specific health status
factors and includes information about specific risk factors in the resident's care? -
Answer-minimum data set
/.In a long-term care setting, these are problem-oriented frameworks for additional
patient assessment based on problem identification items: - Answer-Utilization
guidelines
/.Documenting the full depth and breadth of data use in a healthcare entitiy requires: -
Answer-Identifying the needs of data consumers
/.What is an example of a M-M relationship? - Answer-Patients to consulting physicians
/.What is a M-M relationship? - Answer-Many to many
/.Mrs. Smith was admitted to a hospital by Dr. Collins. Mrs. Smith's hospital bill was paid
by Blue Cross insurance. Upon discharge from the hospital, who owns the health record
of Mrs. Smith? - Answer-University Hospital
/.Decision making and authority over data-related matters is known as: - Answer-data
governance
/.Abbreviations can be a source of patient safety issues due to misinterpretation and
miscommunication. Abbreviations in the health record: - Answer-Should only have one
meaning
/.In ICD-10-PCS what value is used if there is a character that does not apply to a given
code? - Answer-Z
/.The primary responsibility of a coder is to: - Answer-ensure quality of coded data
