Practice Questions for RHIT Exam:
DOMAINs 1, 2, 3 | Questions with 100%
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Technology has advanced to a point at which an unauthorized user can capture data in transit
and alter it. Therefore, CEs must confirm the integrity of data passed across a network. Integrity
is the security principle that protects data from inappropriate modification or corruption. This
includes both unintentional and intentional modifications and destructions. Unintentional
modifications and destruction could occur if the wrong data are destroyed, the wrong backup is
used to restore data, or an electrical fire destroys the computer.
The primary purpose of a data set in healthcare is to:
a. Recommend common data elements to be collected in health records
b. Mandate all data that must be contained in a health record
c. Define reportable data for federally funded programs
d. Standardize medical vocabulary ✔✔a. Recommend common data elements to be collected
in health records
A data set is a recommended list of data elements that have defined and uniformed
definitions that are relevant for a particular use or are specific to a type of healthcare industry.
,A notation for a diabetic patient in a physician progress note reads: "Occasionally gets
hungry. No insulin reactions. She says she is following her diabetic diet." In which part of a
problem-oriented health record progress note would this be written?
a. Subjective
b. Objective
c. Assessment
d. Plan ✔✔a. Subjective
Some providers also use a SOAP format for their problem-oriented progress notes. A subjective
(S) entry relates significant information in the patient's words or from the patient's point
of view.
An audit of a hospital's electronic health system shows that diagnostic codes are not
being reported at the correct level of detail. This indicates a problem with data:
a. Consistency
b. Granularity
c. Comprehensiveness
d. Relevancy ✔✔b. Granularity
,Data granularity requires that the attributes and values of data be defined at the correct level
of detail for the intended use of the data.
In which of the following examples does the gender of the patient constitute information
rather than a data element?
a. As an entry to be completed on the face sheet of the health record
b. In the note "50-year-old white male" in the patient history
c. In a study comparing the incidence of myocardial infarctions in black males as compared
to white females
d. In a study of the age distribution of lung cancer patients ✔✔c. In a study comparing
the incidence of myocardial infarctions in black males as compared to white females
Data are the raw elements that make up our communications. Humans have the innate ability
to combine data they collect and, through all their senses, produce information (which is data
that have been combined to produce value) and enhance that information with experience and
trial-and-error that produces knowledge. In this example, the gender is tied to race in the data
collection that constitutes information and not a data element.
A core data set developed by ASTM to communicate a patient's past and current
health information as the patient transitions from one care setting to another is:
a. Ambulatory Care Data Set
b. Continuity of care record
, c. Minimum Data Set
d. Uniform Hospital Discharge Data Set ✔✔b. Continuity of care record
The continuity of care record (CCR) standard (ASTM E2369-05) is a core data set of relevant
administrative, demographic, and clinical information elements about a patient's health status
and healthcare treatment. It was created to help communicate that information from one
provider to another for referral, transfer, or discharge of the patient.
The home health prospective payment system uses the ________ data set for patient
assessments.
a. HEDIS
b. OASIS-C
c. MDS
d. UHDDS ✔✔b. OASIS-C
The Outcomes and Assessment Information Set (OASIS-C) is a standardized data set designed
to gather data about Medicare beneficiaries who are receiving services from a home health
agency. OASIS-C includes a set of core data items that are collected on all adult home health
patients.
A notation for a hypertensive patient in a physician ambulatory care progress note reads:
"Blood pressure adequately controlled." In which part of a problem-oriented health
record progress note would this be written?
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