RHIT Exam 2024 Questions
with Correct Answers
What is data? - Answer-raw facts and figures
What is information? - Answer-Data converted into meaningful and useful context
What is knowledge? - Answer-information, understanding, and experience that gives
individuals the power to make informed decisions
What is the primary purpose of the health record? - Answer-The primary purposes are
associated directly with the provision of patient care services. Patient care,
management of patient care, and administrative purposes
What is the secondary purpose of the health record? - Answer-Not specifically related to
patient care such as education of healthcare professionals, legal, accreditation, and
policy development, and public health and research
What are the three types of health records? - Answer-Paper, electronic, and hybrid
What is aggregate data? - Answer-Data extracted from individual health records and
combined to form de-identified information about groups of patients that can be
compared and analyzed
What are individual users of the health record? - Answer-Depend on the record to
complete their jobs; ex patient care providers, coding billing staff, patients, employers
What are institutional users of the health record? - Answer-Need access to accomplish
mission such as third party payers, medical review organizations, educational and
accreditation organizations, and policy-making bodies
What is a duplicate health record? - Answer-Patient has 2 or more health record
numbers issued
What is an overlay? - Answer-Patient is erroneously assigned another person's health
record number
What is an overlap? - Answer-When a patient has more than one health record number
at different locations within an enterprise or healthcare organization
,The decision was made to choose a filing system that distributes health records evenly
throughout the filing system. This is known as: - Answer-Terminal digit
_____ is used to assign weight to potential duplicate records. - Answer-Rules-based
algorithm
What is data quality? - Answer-Reliability and effectiveness of data for its intended uses
in operations, decision-making, and planning
The patient's medical history can be completed within ____ days of admission to the
hospital. - Answer-30 days
The fact that ABC hospital is accredited by an accreditation organization that allows the
hospital to also meet the Medicare Conditions of Participation is known as: - Answer-
Deemed Status
Dr. Smith admits patients to ABC hospital. There he is able to perform general surgery,
order tests, and perform other services. This is known as: - Answer-Medical staff
privileges
T or F? Only individuals authorized by the healthcare organization's policies should
allowed to enter documentation in the health record. - Answer-True
T or F? Auto-authentication is the preferred method of authentication. - Answer-False
What portion of clinical data addresses the patient's current complaints, symptoms, and
describes his or her past medical, personal, and family history? - Answer-Medical
History
What portion of clinical data represents the physician's assessment of the patient's
current health status after evaluating the patient's physical condition? - Answer-Physical
Examination
A summary of the patient's health record is found in the: - Answer-Discharge Summary
The assessment used by a rehabilitation center is known as: - Answer-PAI or patient
assessment instrument
What does SOAP stand for? - Answer-S: subjective
O: objective
A: assessment
P: plan
As the government has shifted its focus towards quality, alternative reimbursement and
payment models have developed. An example is - Answer-Pay-for-performance
, What are the three main core components of SNOMED CT? - Answer-Concepts,
descriptions, and relationships
T or F? Nursing terminologies are used for reimbursement of nursing care for Medicare
patients. - Answer-False
T or F? Category I CPT includes E/M, anesthesia, surgery, radiology, pathology and
laboratory, and medicine. - Answer-True
What organization owns the copyrights to CPT? - Answer-American Medical
Association (AMA) but HIPAA mandates it
What governmental body is responsible for maintenance of ICD10-CM? - Answer-
National Center for Health Statistics (NCHS)
What is the state of being diseased including illness, injury, or deviation from normal
health? - Answer-Morbitiy
What federal agency is responsible for ICD-10-PCS? - Answer-CMS
The standard for clinical lab observations is? - Answer-LOINC (Logical Observation
Identifiers, Names, and Codes
Standardizing medical terminology to avoid differences in naming various medical
conditions and procedures (such as the synonyms bunionectomy, McBride procedure,
and repair of hallus valgus) is one purpose of: - Answer-Vocabulary Standards
Ensuring the patient information is reliable and the same across the entire patient
encounter is: - Answer-Data Consistency
Which health record uses an itemized list of the patient's present and past health
problems? - Answer-Problem-Oriented health record
What is the process that allows for connections between two systems? For example,
two different code systems to show equivalent codes allows for data initially captured for
one purpose to be translated and used for another purpose. - Answer-Data Mapping
Who must also be notified of a duplicate health record, after the HIM department has
merged the records? - Answer-The source of the record, example: Laboratory
What type of analysis compared omitted clinical information received from external
providers with the needed clinical information to make a correct diagnosis? - Answer-
Gap Analysis
Who provides oversight for the development, review, and control of forms and computer
screens? - Answer-Clinical Forms Committee
