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RHIT Prep Domain 1: Data Analysis and Management Already Graded A+

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RHIT Prep Domain 1: Data Analysis and Management Already Graded A+ Health Information Management 1. What is a crucial step in designing an electronic health record (EHR)? Answer: Developing a data dictionary. 2. What led to the development of a standardized set of data elements for hospit...

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  • July 23, 2024
  • 9
  • 2023/2024
  • Exam (elaborations)
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RHIT Prep Domain 1: Data Analysis and Management Already
Graded A+


Health Information Management



1. What is a crucial step in designing an electronic health record (EHR)?



Answer: Developing a data dictionary.



2. What led to the development of a standardized set of data elements for hospital discharge abstracts?



Answer: The need to provide comparative data to hospitals.



3. What are two purposes of a data set?



Answer: Identifying data elements to be collected about each patient and providing uniform data
definitions.



4. Where should an HIT consultant start when designing a data collection form for an acute-care
hospital?



Answer: With the Uniform Hospital Discharge Data Set (UHDDS).



5. What is the purpose of the UHDDS?



Answer: To list and define a set of common, uniform data elements.



Record Content and Quality

, 6. What is the process called when deficiencies in health records are identified through analysis?



Answer: Identifying incomplete records.



7. In a paper-based system, where are incomplete records monitored?



Answer: In the incomplete file room.



8. What is the goal of completing a chart in a special area of the HIM department?



Answer: To ensure completeness.



Authentication and Documentation



9. What is authentication in a record?



Answer: Establishing its baseline trustworthiness.



10. How can coding managers address documentation issues with physicians failing to document cause
and effect of diabetes and its manifestations?



Answer: Educating medical staff on their roles in clinical documentation improvement and providing
documentation guidelines.



Assessment ✔️A(n) _____ entry in a SOAP note relates professional conclusions reached from
evaluation of the other information gathered during the encounter. Ex: "Blood pressure adequately
controlled."



Plan ✔️A(n) _____ entry in an a SOAP note relates diagnostic, therapeutic, and educational plans to
resolve the problem.

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