RHIT PRACTICE EXAM 1 TEST QUESTIONS WITH WELL DETAILED SOLUTIONS
A health record technician has been asked to review the discharge patient abstracting
module of a proposed new electronic health record (EHR). Which of the following data sets
would the technician consult to ensure the system collects all federally required discharge
data elements for Medicare and Medicaid inpatients in an acute-care hospital?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS
d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-
specific items on every inpatient.
Standardizing medical terminology to avoid differences in naming various health
conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and
repair of hallux valgus) is one purpose of:
a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards
d. Vocabulary standards
,Vocabulary standards are a list or collection of clinical words or phrases with their
meanings; also, the set of words used by an individual or group within a particular subject
field, such as to provide consistent descriptions of medical terms for an individual's
condition in the health record.
Before healthcare organizations can provide services, they usually must obtain this from
government entities such as the state or county in which they are located.
a. Accreditation
b. Certification
c. Licensure
d. Permission
c. Licensure
Licensure is the state's act of granting a healthcare organization or individual practitioner
the right to provide healthcare services of a defined scope in a limited geographic area. It is
illegal in all 50 states to operate healthcare facilities and practice medicine without a
license.
The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary: definition: date patient admitted to the hospital; data type: date; field length:
15; required field: yes; default value: none; template: none. For this data element, data
integrity would be better assured if:
a. The template was defined
b. The data type was numeric
c. The field was not required
d. The field length was longer
,a. The template was defined
A pattern used in computer-based patient records to capture data in a structured manner
is called a template. One benefit of using a template is to ensure data integrity upon data
entry.
In designing an input screen for an EHR, which of the following would be best to capture
structured data?
a. Speech recognition
b. Drop-down menus
c. Natural language processing
d. Document imaging
b. Drop-down menus
Structured data are data that are able to be read and interpreted by a computer. Examples
of structured data include check boxes, drop-down boxes, and radio buttons.
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?
a. Develop a list of all data elements referencing patients that are included in both paper
and electronic systems of the practice
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements
affecting the release of health records
, c. Perform a quality check on all health record systems in the practice
d. Develop a listing and categorize all information requests for health information over the
past two years
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements
affecting the release of health records
The HIM professional should advise the medical group practice to develop a list of statutes,
regulations, rules, and guidelines regarding the release of the health record as the first step
in determining the components of the legal health records.
Hospital documentation related to the delivery of patient care such as health records, x-
rays, laboratory reports, and consultation reports are owned:
a. By the hospital
b. By the patient
c. By the attending and consulting physician
d. Jointly by the hospital, physician, and patient
a. By the hospital
Health records, x-rays, laboratory reports, consultation reports, and other physical
documents relating to the delivery of patient care are owned by the healthcare
organization.
Copies of personal health records (PHRs) are considered part of the legal health record
when:
A health record technician has been asked to review the discharge patient abstracting
module of a proposed new electronic health record (EHR). Which of the following data sets
would the technician consult to ensure the system collects all federally required discharge
data elements for Medicare and Medicaid inpatients in an acute-care hospital?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS
d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-
specific items on every inpatient.
Standardizing medical terminology to avoid differences in naming various health
conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and
repair of hallux valgus) is one purpose of:
a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards
d. Vocabulary standards
,Vocabulary standards are a list or collection of clinical words or phrases with their
meanings; also, the set of words used by an individual or group within a particular subject
field, such as to provide consistent descriptions of medical terms for an individual's
condition in the health record.
Before healthcare organizations can provide services, they usually must obtain this from
government entities such as the state or county in which they are located.
a. Accreditation
b. Certification
c. Licensure
d. Permission
c. Licensure
Licensure is the state's act of granting a healthcare organization or individual practitioner
the right to provide healthcare services of a defined scope in a limited geographic area. It is
illegal in all 50 states to operate healthcare facilities and practice medicine without a
license.
The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary: definition: date patient admitted to the hospital; data type: date; field length:
15; required field: yes; default value: none; template: none. For this data element, data
integrity would be better assured if:
a. The template was defined
b. The data type was numeric
c. The field was not required
d. The field length was longer
,a. The template was defined
A pattern used in computer-based patient records to capture data in a structured manner
is called a template. One benefit of using a template is to ensure data integrity upon data
entry.
In designing an input screen for an EHR, which of the following would be best to capture
structured data?
a. Speech recognition
b. Drop-down menus
c. Natural language processing
d. Document imaging
b. Drop-down menus
Structured data are data that are able to be read and interpreted by a computer. Examples
of structured data include check boxes, drop-down boxes, and radio buttons.
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?
a. Develop a list of all data elements referencing patients that are included in both paper
and electronic systems of the practice
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements
affecting the release of health records
, c. Perform a quality check on all health record systems in the practice
d. Develop a listing and categorize all information requests for health information over the
past two years
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements
affecting the release of health records
The HIM professional should advise the medical group practice to develop a list of statutes,
regulations, rules, and guidelines regarding the release of the health record as the first step
in determining the components of the legal health records.
Hospital documentation related to the delivery of patient care such as health records, x-
rays, laboratory reports, and consultation reports are owned:
a. By the hospital
b. By the patient
c. By the attending and consulting physician
d. Jointly by the hospital, physician, and patient
a. By the hospital
Health records, x-rays, laboratory reports, consultation reports, and other physical
documents relating to the delivery of patient care are owned by the healthcare
organization.
Copies of personal health records (PHRs) are considered part of the legal health record
when:
