RHIT EXAM ACTUAL DOMAIN 1: DATA CONTENT, STRUCTURE, AND INFORMATION
GOVERNANCE (COMBINED) TEST QUESTIONS WITH ACCURATE SOLUTIONS
The HIM manager is conducting a study in which she is comparing the current year's
diagnosis codes to the proposed new codes for the next fiscal year and documenting
variations in order to assess the impact on the organization. This process creates a
data map
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
the template was defined
In data matching which of the following best describes an overlap?
When one entity has different unique identifiers in different databases
In a database the LAST_NAME column in a table would be considered a
Date Element
Cancer registries are maintained by hospitals
Voluntarily or by state law
,Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the
patient. Which quality element is missing from the progress note?
Data currency
Which of the following is characteristic of the legal health record?
It is the record disclosed upon request - The legal health record distinction is important for
several reasons. First, it is important to an organization's business and legal processes.
Second, because the legal health record is the record that is produced upon request,
including legal requests, it becomes important to ensure that the legal health record is
legally sound and defensible as a valid document in legal situations
Why does an ideal EHR system require point-of-care charting?
Ensures that appropriate data are collected timely - Many hospitals begin their EHR
implementation with point of care (POC) charting systems. These systems provide context-
sensitive templates. Templates ensure that the appropriate data are collected and guide
users in adhering to professional practice standards. These might include nursing
admission assessments, nursing progress notes, vital signs charting, intake and output
records, and the like
Metadata
are data about data and include information that track actions such as when and by whom
a document was accessed or changed
Which of the following is the best example of a data governance business case?
Data silos and fragmented data inhibit data integration - The case for data governance is
compelling if we look at the degree to which business processes are dependent on access
,to good data. The best example for a data governance business case is data in silos or
fragmented data which inhibit data integration
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase.
Which of the following data sets should the clinic consult to ensure that all the federally
recommended data elements for Medicare and Medicaid outpatients are collected by the
system?
UACDS - The Uniform Ambulatory Care Data Set (UACDS) data characteristics include
patient-specific items for outpatient care
Which of the following should be avoided when designing forms for an electronic
document management system (EDMS)?
Shading of bars or lines that contain text - The use of colored paper or ink other than black,
or shading of text in EDMS should be minimized or eliminated because the color can
adversely affect the quality of scanned images
The evaluation of data collected based on business needs and strategy is part of
Data stewardship - Data stewardship is the evaluation of the data collection based on
business need and strategy to ensure the data meets the requirements of patient care and
organizational needs. Data stewardship and data ownership are closely connected
How do patient care managers use the data documented in the health record?
Evaluate the performance of employees - It is the role of the patient care managers and
support staff to evaluate the performance of employees
, Which of the following Enterprise Information Management (EIM) functions is the
overarching authority for managing an organization's data assets?
Data governance - Which of the following Enterprise Information Management (EIM)
functions is the overarching authority for managing an organization's data assets?
Which of the following is the healthcare industry's leading standards-setting body in the
country?
National Committee for quality Assurance - Although there are many high quality
accreditation organizations in existence today, all with the common goals of patient safety
and the delivery of high quality healthcare to patients, the Joint Commission has been an
industry leader in the area of healthcare provider organization accreditation
Which of the following is not true of good electronic forms design?
Uses radio buttons to select multiple items from a set of options. - Good forms design is
needed within an EHR to create ease of use. The use of a selection box allows the user to
select a value from a predefined list. Check boxes are used for multiple selections and
radio buttons are used for single selections
The link that tracks patient, person, or member activity within healthcare organizations and
across patient care settings is known as:
Audit trail
Managing an organization's data and those who enter it is an ongoing challenge requiring
active administration and oversight. This can be accomplished by the organization through
management of which of the following?
GOVERNANCE (COMBINED) TEST QUESTIONS WITH ACCURATE SOLUTIONS
The HIM manager is conducting a study in which she is comparing the current year's
diagnosis codes to the proposed new codes for the next fiscal year and documenting
variations in order to assess the impact on the organization. This process creates a
data map
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
the template was defined
In data matching which of the following best describes an overlap?
When one entity has different unique identifiers in different databases
In a database the LAST_NAME column in a table would be considered a
Date Element
Cancer registries are maintained by hospitals
Voluntarily or by state law
,Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the
patient. Which quality element is missing from the progress note?
Data currency
Which of the following is characteristic of the legal health record?
It is the record disclosed upon request - The legal health record distinction is important for
several reasons. First, it is important to an organization's business and legal processes.
Second, because the legal health record is the record that is produced upon request,
including legal requests, it becomes important to ensure that the legal health record is
legally sound and defensible as a valid document in legal situations
Why does an ideal EHR system require point-of-care charting?
Ensures that appropriate data are collected timely - Many hospitals begin their EHR
implementation with point of care (POC) charting systems. These systems provide context-
sensitive templates. Templates ensure that the appropriate data are collected and guide
users in adhering to professional practice standards. These might include nursing
admission assessments, nursing progress notes, vital signs charting, intake and output
records, and the like
Metadata
are data about data and include information that track actions such as when and by whom
a document was accessed or changed
Which of the following is the best example of a data governance business case?
Data silos and fragmented data inhibit data integration - The case for data governance is
compelling if we look at the degree to which business processes are dependent on access
,to good data. The best example for a data governance business case is data in silos or
fragmented data which inhibit data integration
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase.
Which of the following data sets should the clinic consult to ensure that all the federally
recommended data elements for Medicare and Medicaid outpatients are collected by the
system?
UACDS - The Uniform Ambulatory Care Data Set (UACDS) data characteristics include
patient-specific items for outpatient care
Which of the following should be avoided when designing forms for an electronic
document management system (EDMS)?
Shading of bars or lines that contain text - The use of colored paper or ink other than black,
or shading of text in EDMS should be minimized or eliminated because the color can
adversely affect the quality of scanned images
The evaluation of data collected based on business needs and strategy is part of
Data stewardship - Data stewardship is the evaluation of the data collection based on
business need and strategy to ensure the data meets the requirements of patient care and
organizational needs. Data stewardship and data ownership are closely connected
How do patient care managers use the data documented in the health record?
Evaluate the performance of employees - It is the role of the patient care managers and
support staff to evaluate the performance of employees
, Which of the following Enterprise Information Management (EIM) functions is the
overarching authority for managing an organization's data assets?
Data governance - Which of the following Enterprise Information Management (EIM)
functions is the overarching authority for managing an organization's data assets?
Which of the following is the healthcare industry's leading standards-setting body in the
country?
National Committee for quality Assurance - Although there are many high quality
accreditation organizations in existence today, all with the common goals of patient safety
and the delivery of high quality healthcare to patients, the Joint Commission has been an
industry leader in the area of healthcare provider organization accreditation
Which of the following is not true of good electronic forms design?
Uses radio buttons to select multiple items from a set of options. - Good forms design is
needed within an EHR to create ease of use. The use of a selection box allows the user to
select a value from a predefined list. Check boxes are used for multiple selections and
radio buttons are used for single selections
The link that tracks patient, person, or member activity within healthcare organizations and
across patient care settings is known as:
Audit trail
Managing an organization's data and those who enter it is an ongoing challenge requiring
active administration and oversight. This can be accomplished by the organization through
management of which of the following?
