RHIT Domain 1 Verified Answers
Health Information Management
1. Who acts as a bridge between information technology, business, and clinical areas, managing key data
areas?
Answer: Data steward.
2. What type of data set is useful for developing a hospital trauma data registry?
Answer: DE...
1. Who acts as a bridge between information technology, business, and clinical areas, managing key data
areas?
Answer: Data steward.
2. What type of data set is useful for developing a hospital trauma data registry?
Answer: DEEDS (Data Elements for Emergency Department Systems).
3. What is the best definition of a forward map in data mapping?
Answer: Linking an older version of a code set to a newer version.
4. What is the status conferred by a national professional organization dedicated to a specific area of
healthcare practice?
Answer: Credential.
5. What must a healthcare provider organization do when defining its legal health record?
Answer: Assess the legal environment, system limitations, and HIE agreements.
6. Which standards must a skilled nursing facility meet to participate in federal government
reimbursement programs like Medicare and Medicaid?
Answer: Conditions of Participation.
Record Content and Quality
7. How can HIM directors ensure the completeness of health records?
Answer: Review each patient's health record concurrently to ensure that history and physicals are
present.
,8. Who assists the HIM department in assigning the health record number?
Answer: Patient registration department.
9. In which section of an acute-care record would you find documentation of a physical examination?
Answer: Physical examination.
10. What is the act of granting approval to a healthcare organization based on meeting voluntary
standards called?
Answer: Accreditation.
11. What is a secondary purpose of the health record?
Answer: Support for research.
12. What is necessary to ensure that each term used in an EHR has a common meaning to all users?
Answer: Controlled vocabulary.
Authentication and Documentation
13. What does authentication of a record refer to?
Answer: Establishment of its baseline trustworthiness.
14. How can coding managers address documentation issues with physicians failing to document cause
and effect of diabetes and its manifestations?
Answer: Educate the medical staff on their roles in clinical documentation improvement and provide
documentation guidelines.
The advent of the electronic health record (EHR) came with improvements as well as challenges related
to clinical documentation. Overall, the EHR has increased the amount of documentation based largely
on the ease of entry (Hess 2015, 124).
,Which of the following is an example of clinical data?
a. Admitting diagnosis
b. Date and time of admission
c. Insurance information
d. Health record number ✔️a
The health record generally contains two types of data: clinical and administrative. Clinical data
document the patient's health condition, diagnosis, and procedures performed as well as the healthcare
treatment provided. Administrative data include demographic and financial information as well as
various consents and authorizations related to the provision of care and the handling of confidential
patient information (Brickner 2016, 90).
Which of the following is an institutional user of the health record?
a. A third-party payer
b. Patient
c. Physician
d. Employer ✔️a
Institutional users of the health record are organizations that need access to health records in order to
accomplish their mission. These institutional users include healthcare delivery organizations, third-party
payers, medical review organizations, research organizations, educational organizations, accreditation
organizations, government licensing agencies, and policy-making bodies (Sayles 2016b, 54-55).
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Registered Health I
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?
, a. Call the EHR vendor and ask to review the system's data dictionary
b. Identify data content requirements for all areas of the organization
c. Schedule a meeting with all department directors to get their input
d. Contact CMS to determine what data sets are required to be collected ✔️b
Data content standards allow organizations to collect data once and use it many times in many ways.
They also assist in data storage and mining as well as sharing data with external organizations for use in
benchmarking and other purposes. The HIM director should identify data content requirements for all
areas of the organization to ensure the data content standards are met (Sayles and Trawick 2014, 170).
Which of the following would be the best technique to ensure that registration clerks consistently use
the correct notation for assigning admission date in an EHR?
a. Make admission date a required field
b. Provide a template for entering data in the field
c. Make admission date a numeric field
d. Provide sufficient space for input of data ✔️b
Templates are a cross between free text and structured data entry. The user is able to pick and choose
data that are entered frequently, thus requiring the entry of data that change from patient to patient.
Templates can be customized to meet the needs of the organization as data needs change by physician
specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this
situation a template would provide structured data entry for the admission date (Brinda 2016, 159-160).
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
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