RHIA domain 1 Questions And Answers Rated 100% Correct!!
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RHIA domain 1
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RHIA Domain 1
Which of the following is used by a long-term care facility to gather information about
specific health status factors and includes information about specific risk factors in the
resident's care? - ️️minimum data set
Mr. Smith was admitted to University Hospital by Dr. Collins. Mr. Smith's h...
RHIA domain 1
Which of the following is used by a long-term care facility to gather information about
specific health status factors and includes information about specific risk factors in the
resident's care? - ✔️✔️minimum data set
Mr. Smith was admitted to University Hospital by Dr. Collins. Mr. Smith's hospital bill will
be paid by Blue Cross Insurance. Upon discharge from the hospital, who owns the
health record of Mr. Smith? - ✔️✔️University Hospital
structured information used to increase the effective use of data - ✔️✔️metadata
data element name, data type, and field length are examples of what kind of data -
✔️✔️metadata
all documentation entered in the medical record relating to the patient's diagnosis and
treatment are considered this type of data - ✔️✔️clinical data
. A 65-year-old white male was admitted to the hospital on 1/15 complaining of
abdominal pain. The attending physician requested an upper GI series and laboratory
evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA
showed an increased white blood cell count. The patient was taken to surgery for an
exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint
was: - ✔️✔️abdominal pain
n ICD-10-PCS, what value is used if there is a character that does not apply to a given
code? - ✔️✔️Z
required elements in an emergency care record - ✔️✔️time and means of the patient's
arrival, treatment rendered, instructions at discharge
In a long-term care setting, these are problem-oriented frameworks for additional patient
assessment based on problem identification items (triggered conditions): -
✔️✔️Resident Assessment Protocols (RAPs)
a data element name is considered which of the following:
a. master data
b. metadata
c. structured data
d. unstructured data - ✔️✔️b
, What type of information makes it easy for hospitals to compare and combine the
contents of multiple patient health records? - ✔️✔️uniform data sets
component of the resident assessment instrument (RAI) used to collect information
about the resident's risk factors and plans ongoing care and treatment of the resident at
the LTC facility - ✔️✔️minimum data set
Documenting the full depth and breadth of data use in a healthcare entity requires: -
✔️✔️identifying the needs of the data consumers
The primary responsibility of a coder is to: - ✔️✔️ensure accuracy of coded data
Notes written by physicians and other practitioners as well as dictated and transcribed
reports are examples of: - ✔️✔️unstructured data
Data that have been grouped into meaningful categories according to a classification
system are referred to as this type of data - ✔️✔️coded
Which part of the problem-oriented health record is used by many facilities that have
adopted the whole problem-oriented format? - ✔️✔️The SOAP form of progress notes
Borrowing record entries from another source as well as representing or displaying past
documentation as current are examples of a potential breach of: - ✔️✔️authorship
integrity
According to Joint Commission Accreditation Standards, which document must be
placed in the patient's record before a surgical procedure may be performed? -
✔️✔️history and physical
Data that are collected on large populations of individuals and stored in databases are
referred to as: - ✔️✔️aggregate data
Decision making and authority over data-related matters is known as - ✔️✔️data
governance
contains a summary of the care provided in the facility from which the patient is being
transferred as well as the reason for transfer - ✔️✔️transfer record
Mildred Smith was admitted to a nursing facility with the following information: "Patient is
being admitted for Organic Brain Syndrome." Underneath the diagnosis her medical
information was listed along with a summary of the care already provided. This
information is documented on the: - ✔️✔️transfer record
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