RHIA Domain 1 Exam with Questions and 100% Correct Answers
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RHIA Domain 1
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RHIA Domain 1
A set of standardized terms and their synonyms that record patient findings, circumstances,
events, and interventions with sufficient detail to support clinical care, clinical decisions,
outcomes research, and quality improvement. - Answer Clinical terminology
A recognized system of terms used i...
RHIA Domain 1 Exam with Questions and
100% Correct Answers
A set of standardized terms and their synonyms that record patient findings, circumstances,
events, and interventions with sufficient detail to support clinical care, clinical decisions,
outcomes research, and quality improvement. - Answer Clinical terminology
A recognized system of terms used in a science or art that follows preestablished naming
conventions. A disease nomenclature is a listing of the proper name for each disease entity with
its specific code number.
When a vocabulary assigns a name to a concept, it is defined as a nomenclature.
This is the process of identifying/describing the link between two (or more) distinct databases
(models). It is a process of "cross-referencing/cross-linking" between current terminology and
new terminology in an organization or between organizations.
Data mapping has an important role as we move forward with the EHR and data is stored in
legacy systems. Linking current terms to past terms will allow for continued collection of
healthcare data. The implementation of ICD-10-CM/PCS, created the need to link data in ICD-
10-CM/PCS to ICD-9-CM. It is important to know that coded data collected prior to October 1,
2015, used ICD-9-CM. - Answer Data Mapping
,User needs, documentation responsibilities, Identification of forms and views, documentation
guidelines and format types are: - Answer The data collection principles.
Flowchart - Answer ________________s provide a graphical depiction of the sequencing of the
steps in a process.
_______________ charts illustrate hierarchical relationships between entities. - Answer
Organizational
________________ are useful to present projected indications for achievement of deadlines. -
Answer Timelines
______________are used to provide likely completion times for projects, using smaller projects
to accomplish larger goals. - Answer PERT Chart
__________________ are a common project scheduling tool, used to emphasize the work time
needed to meet an identified goal. - Answer Gantt Charts
Completeness of the health record is determined by the performance of daily
__________________ - Answer quantitative, qualitative, legal, and statistical analysis.
What are 7 Important items for consideration when exploring work flow are: - Answer traffic
patterns
Functions to be performed
Confidentiality concerns
Shared work space
Flexibility for future needs
Ergonomics
Environment considerations
, An _________________is an alteration of the health information by
modification, correction, addition, or deletion. There are many terms used that ultimately
amend the health record. For the purpose of this toolkit, the term "amendment" is the
overarching term indicating that documentation has been
altered. - Answer Amendments
Entries added to a health record to provide additional
information in conjunction with a previous entry. The
addendum should be timely, bear the current date, time,
and reason for the additional information being added to
the health record, and be electronically signed. - Answer Addendum
A ____________ is a change in the information meant to clarify
inaccuracies after the original electronic document has been signed or rendered complete.
Corrections may also involve removing information from one record and posting it to another
within the electronic document management system. - Answer Correction
A ________is the action of correcting information that was
incorrect, invalid, or made in error, and preventing its display or hiding the entry or
documentation from further general views. However, the original information is available in the
previous version. An annotation should be viewable to the clinical staff so that the retracted
document can be consulted if needed. - Answer Retraction
A ________is the action of permanently eliminating information that is not tracked in a
previous version. Most EHRs do not allow permanent deletion. - Answer Deletion
Late Entry - Answer An addition to the health record when a pertinent entry was missed or was
not written in a timely manner.1 The late entry should be timely, bear the current date, time,
and reason for the additional information being added to the health record
and be electronically signed.
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