RHIT Exam Domain 1 Study Guide
A health record technician has been asked to review the discharge patient abstracting module of a proposed new 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?(Ans- UHDDS
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:
(Ans- Vocabulary standards
Patient care managers use the data documented in the health record to:
(Ans- Evaluate patterns and trends of patient care.
At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed
in reports. This situation reflects a problem in:
(Ans- Data consistency
A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information?(Ans- Vital signs record
Which of the following is a key characteristic of the problem-oriented health record.(Ans- Uses an itemized list of the patient's past and present health problems.
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Which of the following is true regarding the reporting of communicable diseases?(Ans- The diseases to be reported are established by state law.
A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?(Ans- Identify data content requirements for all areas of the organization.
A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report?(Ans- Medication administration record and clinical laboratory reports.
Which of the following is considered the authoritative key in locating a health record?(Ans- Master Patient Index
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:
(Ans- Data map
A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report?(Ans- Consultation
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