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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Domain 1 Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%Verified
Data Governance - an emerging practice in the healthcare industry. Decision making and authority over
data-related matters is data governance. It is clear that any industry as reliant on data as healthcare
needs a plan for managing this asset
Aggregate Data - used to develop information about groups of patients
Chief complaint - reason for the visit, nature or duration of the symptoms that caused the patient's
illness and caused the patient to seek medical attention as stated in the patient's own words
Financial Data - includes insured party's member ID #, includes details about patient's occupation,
employer, and insurance coverage- healthcare providers use this data to complete claims forms that will
be submitted to 3rd party payers
Mask - Tells database what format to use to display the #s entered.
Entity-Relationship Diagram (ERD) - Developed to depict relational database structures. Can also be used
to depict conceptual level models for any type of database; but would only be used to model a relational
database at the logical level
SOAP - Subjective, Objective Assessment Plan notes
Part of problem-oriented medical record (POMR) approach most commonly used by physicians and
other healthcare professionals
intended to improve quality and continuity of client services by enhancing communication among
healthcare professionals
Minimum Data Set (MDS) - A component of the resident assessment instrument (RAI) and is used to
collect information about the resident's risk factors and to plan the ongoing care and treatment of the
resident in the long-term care facility.
Used by a long-term care facility to gather information about specific health status factors and includes
information about specific risk factors in the residents care
, Resident Assessment Protocols (RAPs) - Form critical link to decisions about care planning and provide
guidance on how to synthesize assess information within a comprehensive assessment
Unstructured Clinical Information - Notes written by physicians and other practitioners who treat the
patient, dictated and transcribed reports, and legal forms such as consents and advanced directives
Structured Data - Fields are pre-defined and limited- discrete and format of data is structured
Certificate of destruction - date of destruction, method of destruction, description of disposed record
series of numbers or items, inclusive dates covered, a statement that the records were destroyed in the
regular course of business
Principal function of a health record - to serve as the repository of clinical documentation relevant to the
care of individual patients. Principal functions are related to specific healthcare encounters between
providers and patients
M:M Relationship - Many to Many
I.E: Patient: Consulting Physician
In each instance of a patient there could be many instances of consulting physicians
for Each consulting physician there could be many patients
Universal Chart Order System - One in which the patient health record is kept in the same format or
order while the patient is in the facility and after discharge
Retention Program: Who is generally responsible for implementing this and what are the steps - HIM
Director
1. Conduct an inventory of facilities records
2. Determine the format and location of record storage
3. Assign each record a retention period
4. Destroy records that are no longer needed
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