RHIT DOMAIN 1: ESSENTIAL STUDY GUIDE
Which of the following individuals would serve as a bridge between information technology and
business and clinical areas while managing each key area?
a. Data steward
b. Systems analyst
c. Data scientist
d. Systems administrator
a
Data stewards serve as the bridge between information technology, and business and clinical areas.
They are assigned to manage key data areas and are responsible for tasks such as data definition and
information quality activities (Johns 2015, 83).
Which of the following data sets would be most helpful in developing a hospital trauma data registry?
a. DEEDS
b. MDS
c. OASIS
d. UACDS
a
In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury
Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department
Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-
based emergency departments and to reduce incompatibilities in emergency department records (Sharp
2016, 178; Giannangelo 2015, 255).
Which of the following is the best definition of a forward map in data mapping?
a. Linking of two systems in the opposite direction
b. Linking an older version of a code set to a newer version
c. Linking a newer version of a code set to an older version
d. Linking a source system to a target system
b
In a forward map, an older version of a code set is mapped to a newer version (Amatayakul 2016, 285).
,What is the status conferred by a national professional organization that is dedicated to a specific
area of healthcare practice?
a. Degree
b. Certificate
c. License
d. Credential
d
Credentials are the recognition by healthcare organizations of previous professional practice
responsibilities and experiences commonly accorded to licensed independent practitioners and are
usually conferred by a national professional organization dedicated to a specific area of healthcare
practice (Shaw and Carter 2015, 336).
A healthcare provider organization, when defining its legal health record must:
a. Assess the legal environment, system limitations, and HIE agreements
b. Determine what other healthcare provider organizations are doing
c. Determine if a legal health record is needed
d. Only include the paper components of the health record
a
As part of the process to identify the legal health record, the facility should assess the legal
environment, system limitations, and HIE agreements (Brickner 2016, 86-87).
Valley High, a skilled nursing facility, wants to become certified to take part in federal government
reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to
become certified for these programs?
a. Minimum Data Set
b. National Commission on Correctional Health Care
c. Conditions of Participation
d. Outcomes and Assessment Information Set
c
Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the
Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare
organizations that participate in the Medicare program. In other words, participating organizations
receive federal funds from the Medicare program for services provided to patients and thus must follow
the Medicare Conditions of Participation (Brickner 2016, 84, 102).
To comply with the Joint Commission standards, the HIM director wants to be sure that history and
physical examinations are documented in the patient's health record no later than 24 hours after
admission. Which of the following would be the best way to ensure the completeness of the health
record?
a. Establish a process to review health records immediately on discharge
b. Review each patient's health record concurrently to make sure that history and physicals are
,present
c. Retrospectively review each patient's health record to make sure that history and physicals are
present
d. Write a memorandum to all physicians relating the Joint Commission requirements for
documenting history and physical examinations
b
The quantitative analysis or record content review process can be handled in a number of ways. Some
acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using
this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review
each patient's record. This type of process is usually referred to as a concurrent review because review
occurs concurrently with the patient's stay in the hospital (Sayles 2016b, 64).
The patient registration department assists the HIM department in what way?
a. Assigning the health record number
b. Processing the healthcare claim
c. Implementing the information systems used by the HIM department
d. Maintaining the information systems used by the HIM department
a
The health record typically begins in patient registration with the capture of patient demographic
information. The health record is assigned to new patients during the patient registration process. The
HIM department works with patient registration to ensure the quality of the data collected and to
correct duplicate and other issues with the MPI (Sayles 2016b, 74).
The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes,
nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In
which of the following would this documentation appear?
a. Medical history
b. Pathology report
c. Operation report
d. Physical examination
d
Information usually documented in the physical examination includes vital signs and examinations of the
head, eyes, ears, nose, throat (HEENT) (Brickner 2016, 91-92).
The act of granting approval to a healthcare organization based on whether the organization has met
a set of voluntary standards is called:
a. Accreditation
b. Licensure
c. Acceptance
d. Approval
, a
Accreditation is the act of granting approval to a healthcare organization. The approval is based on
whether the organization has met a set of voluntary standards that were developed by the accreditation
agency. Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation
or certification. The Joint Commission is an example of an accreditation agency (Shaw and Carter 2015,
406).
A secondary purpose of the health record is to provide support for which of the following?
a. Provider reimbursement
b. Patient self-management activities
c. Research
d. Patient care delivery
c
The secondary purposes of the health record are not associated with specific encounters between
patient and healthcare professional. Rather, they are related to the environment in which patient care is
provided. Some secondary purposes are: support for research, to serve as evidence in litigation, to
allocate resources, to plan market strategy, and the like (Sayles 2016b, 52-53).
Which of the following is necessary to ensure that each term used in an EHR has a common meaning
to all users?
a. Controlled vocabulary
b. Data exchange standards
c. Encoded vocabulary
d. Proprietary standards
a
The vocabulary used in an electronic health record (EHR) system should, at a minimum, be a controlled
vocabulary, which is essential in ensuring a common meaning for all users. A controlled vocabulary
means that a specific set of terms in the EHR's data dictionary may be used and that a central authority
approves any additions or changes (Sayles 2016a, 4-7).
Authentication of a record refers to:
a. Establishment of its baseline trustworthiness
b. The type of electronic operating system on which it was created
c. The identity of the individual who notarized it
d. Its relevance
a
Even if evidence appears to be relevant, it must also be authenticated. As with health records, the
evidence itself must be shown to have a baseline authenticity or trustworthiness (Klaver 2017a, 78-79).
Which of the following individuals would serve as a bridge between information technology and
business and clinical areas while managing each key area?
a. Data steward
b. Systems analyst
c. Data scientist
d. Systems administrator
a
Data stewards serve as the bridge between information technology, and business and clinical areas.
They are assigned to manage key data areas and are responsible for tasks such as data definition and
information quality activities (Johns 2015, 83).
Which of the following data sets would be most helpful in developing a hospital trauma data registry?
a. DEEDS
b. MDS
c. OASIS
d. UACDS
a
In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury
Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department
Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-
based emergency departments and to reduce incompatibilities in emergency department records (Sharp
2016, 178; Giannangelo 2015, 255).
Which of the following is the best definition of a forward map in data mapping?
a. Linking of two systems in the opposite direction
b. Linking an older version of a code set to a newer version
c. Linking a newer version of a code set to an older version
d. Linking a source system to a target system
b
In a forward map, an older version of a code set is mapped to a newer version (Amatayakul 2016, 285).
,What is the status conferred by a national professional organization that is dedicated to a specific
area of healthcare practice?
a. Degree
b. Certificate
c. License
d. Credential
d
Credentials are the recognition by healthcare organizations of previous professional practice
responsibilities and experiences commonly accorded to licensed independent practitioners and are
usually conferred by a national professional organization dedicated to a specific area of healthcare
practice (Shaw and Carter 2015, 336).
A healthcare provider organization, when defining its legal health record must:
a. Assess the legal environment, system limitations, and HIE agreements
b. Determine what other healthcare provider organizations are doing
c. Determine if a legal health record is needed
d. Only include the paper components of the health record
a
As part of the process to identify the legal health record, the facility should assess the legal
environment, system limitations, and HIE agreements (Brickner 2016, 86-87).
Valley High, a skilled nursing facility, wants to become certified to take part in federal government
reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to
become certified for these programs?
a. Minimum Data Set
b. National Commission on Correctional Health Care
c. Conditions of Participation
d. Outcomes and Assessment Information Set
c
Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the
Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare
organizations that participate in the Medicare program. In other words, participating organizations
receive federal funds from the Medicare program for services provided to patients and thus must follow
the Medicare Conditions of Participation (Brickner 2016, 84, 102).
To comply with the Joint Commission standards, the HIM director wants to be sure that history and
physical examinations are documented in the patient's health record no later than 24 hours after
admission. Which of the following would be the best way to ensure the completeness of the health
record?
a. Establish a process to review health records immediately on discharge
b. Review each patient's health record concurrently to make sure that history and physicals are
,present
c. Retrospectively review each patient's health record to make sure that history and physicals are
present
d. Write a memorandum to all physicians relating the Joint Commission requirements for
documenting history and physical examinations
b
The quantitative analysis or record content review process can be handled in a number of ways. Some
acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using
this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review
each patient's record. This type of process is usually referred to as a concurrent review because review
occurs concurrently with the patient's stay in the hospital (Sayles 2016b, 64).
The patient registration department assists the HIM department in what way?
a. Assigning the health record number
b. Processing the healthcare claim
c. Implementing the information systems used by the HIM department
d. Maintaining the information systems used by the HIM department
a
The health record typically begins in patient registration with the capture of patient demographic
information. The health record is assigned to new patients during the patient registration process. The
HIM department works with patient registration to ensure the quality of the data collected and to
correct duplicate and other issues with the MPI (Sayles 2016b, 74).
The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes,
nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In
which of the following would this documentation appear?
a. Medical history
b. Pathology report
c. Operation report
d. Physical examination
d
Information usually documented in the physical examination includes vital signs and examinations of the
head, eyes, ears, nose, throat (HEENT) (Brickner 2016, 91-92).
The act of granting approval to a healthcare organization based on whether the organization has met
a set of voluntary standards is called:
a. Accreditation
b. Licensure
c. Acceptance
d. Approval
, a
Accreditation is the act of granting approval to a healthcare organization. The approval is based on
whether the organization has met a set of voluntary standards that were developed by the accreditation
agency. Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation
or certification. The Joint Commission is an example of an accreditation agency (Shaw and Carter 2015,
406).
A secondary purpose of the health record is to provide support for which of the following?
a. Provider reimbursement
b. Patient self-management activities
c. Research
d. Patient care delivery
c
The secondary purposes of the health record are not associated with specific encounters between
patient and healthcare professional. Rather, they are related to the environment in which patient care is
provided. Some secondary purposes are: support for research, to serve as evidence in litigation, to
allocate resources, to plan market strategy, and the like (Sayles 2016b, 52-53).
Which of the following is necessary to ensure that each term used in an EHR has a common meaning
to all users?
a. Controlled vocabulary
b. Data exchange standards
c. Encoded vocabulary
d. Proprietary standards
a
The vocabulary used in an electronic health record (EHR) system should, at a minimum, be a controlled
vocabulary, which is essential in ensuring a common meaning for all users. A controlled vocabulary
means that a specific set of terms in the EHR's data dictionary may be used and that a central authority
approves any additions or changes (Sayles 2016a, 4-7).
Authentication of a record refers to:
a. Establishment of its baseline trustworthiness
b. The type of electronic operating system on which it was created
c. The identity of the individual who notarized it
d. Its relevance
a
Even if evidence appears to be relevant, it must also be authenticated. As with health records, the
evidence itself must be shown to have a baseline authenticity or trustworthiness (Klaver 2017a, 78-79).
