RHIT DOMAIN 1 PRACTICE QUESTIONS: HIGH-
YIELD REVIEW
Creekside Care, 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?
Minimum Data Set
National Commission on Correctional Health Care
Medicare Conditions of Participation
Outcomes and Assessment Information Set
Medicare Conditions of Participation
Feedback: 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 2020a, 97).
To comply with the Joint Commission standards, the HIM director wants to ensure the 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?
Establish a process to review health records immediately on discharge.
Review each patient's health record concurrently to ensure the history and physicals are present.
Retrospectively review each patient's health record to ensure the history and physicals are present.
Write a memorandum to all physicians relating the Joint Commission requirements for documenting
history and physical examinations.
,Review each patient's health record concurrently to ensure the history and physicals are present.
Feedback: 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 2020b, 76-77).
Which type of data identifies the patient (such as name, health record number, address, and
telephone number)?
Accession data
Indicator data
Reference data
Demographic data
Demographic data
Feedback: Demographic data is used to identify an individual, such as name, address, gender, age, and
other information linked to a specific person (Gordon, M. L. 2020, 474).
Two coding professionals have found the same abbreviation in two records. One abbreviation of
"O.D." was used on an eye health record to mean "right eye." The other abbreviation in another
patient's record was used to mean "overdose" in an abuse record. What data quality component is
lacking here?
Timeliness
Completeness
Security
Consistency
Consistency
Feedback: Characteristics for data entry should be uniform throughout the health record to ensure
consistency. Data must have definitions and be uniform to prevent information inconsistencies (Sayles
and Kavanaugh-Burke 2021, 25).
Cancer registries are maintained by hospitals:
By federal law or state law
Voluntarily or by state law
Voluntarily or by federal law
By mandate from the American College of Surgeons
Voluntarily or by state law
Feedback: Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by
, state law. Many states require that hospitals report their data to a central statewide registry or
incidence surveillance program (Sharp 2020, 202).
Which of the following data sets would be most helpful in developing a hospital trauma data registry?
DEEDS
MDS
OASIS
UACDS
DEEDS
Feedback: Data Elements for Emergency Department Systems (DEEDS) is a data set to support the
uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in
emergency department records. Because DEEDS is based on emergency department records it would be
helpful in developing a trauma registry (Brinda 2020, 156).
Which of the following represents the required documentation elements needed to be included in a
patient's health record when a surgical procedure is performed?
Operative report, anesthesia report, recovery room report
Discharge summary, anesthesia report, operative report
Recovery room report, physical therapy notes, operative report
Operative report, discharge summary, anesthesia report
Operative report, anesthesia report, recovery room report
Feedback: Any surgical procedure requires special documentation. The entire process is recorded with
an anesthesia report, operative report, and recovery room report (Brickner 2020a, 108-109).
The master patient index (MPI) manager has identified a pattern of duplicate health record numbers
from the specimen processing area of the hospital. The MPI manager merged the patient information
and corrected the duplicates in the patient information system. After this merging process, which
department should the MPI manager notify to correct the source system data?
Laboratory
Radiology
Quality Management
Registration
Laboratory
Feedback: As the HIM department merges two duplicates together, the source system (laboratory) also
must be corrected. This creates new challenges for organizations because merge functionality could be
different in each system or module, which in turn creates data redundancy. When duplicates are
identified, the department managers need to be notified. Addressing ongoing errors within the MPI
YIELD REVIEW
Creekside Care, 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?
Minimum Data Set
National Commission on Correctional Health Care
Medicare Conditions of Participation
Outcomes and Assessment Information Set
Medicare Conditions of Participation
Feedback: 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 2020a, 97).
To comply with the Joint Commission standards, the HIM director wants to ensure the 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?
Establish a process to review health records immediately on discharge.
Review each patient's health record concurrently to ensure the history and physicals are present.
Retrospectively review each patient's health record to ensure the history and physicals are present.
Write a memorandum to all physicians relating the Joint Commission requirements for documenting
history and physical examinations.
,Review each patient's health record concurrently to ensure the history and physicals are present.
Feedback: 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 2020b, 76-77).
Which type of data identifies the patient (such as name, health record number, address, and
telephone number)?
Accession data
Indicator data
Reference data
Demographic data
Demographic data
Feedback: Demographic data is used to identify an individual, such as name, address, gender, age, and
other information linked to a specific person (Gordon, M. L. 2020, 474).
Two coding professionals have found the same abbreviation in two records. One abbreviation of
"O.D." was used on an eye health record to mean "right eye." The other abbreviation in another
patient's record was used to mean "overdose" in an abuse record. What data quality component is
lacking here?
Timeliness
Completeness
Security
Consistency
Consistency
Feedback: Characteristics for data entry should be uniform throughout the health record to ensure
consistency. Data must have definitions and be uniform to prevent information inconsistencies (Sayles
and Kavanaugh-Burke 2021, 25).
Cancer registries are maintained by hospitals:
By federal law or state law
Voluntarily or by state law
Voluntarily or by federal law
By mandate from the American College of Surgeons
Voluntarily or by state law
Feedback: Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by
, state law. Many states require that hospitals report their data to a central statewide registry or
incidence surveillance program (Sharp 2020, 202).
Which of the following data sets would be most helpful in developing a hospital trauma data registry?
DEEDS
MDS
OASIS
UACDS
DEEDS
Feedback: Data Elements for Emergency Department Systems (DEEDS) is a data set to support the
uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in
emergency department records. Because DEEDS is based on emergency department records it would be
helpful in developing a trauma registry (Brinda 2020, 156).
Which of the following represents the required documentation elements needed to be included in a
patient's health record when a surgical procedure is performed?
Operative report, anesthesia report, recovery room report
Discharge summary, anesthesia report, operative report
Recovery room report, physical therapy notes, operative report
Operative report, discharge summary, anesthesia report
Operative report, anesthesia report, recovery room report
Feedback: Any surgical procedure requires special documentation. The entire process is recorded with
an anesthesia report, operative report, and recovery room report (Brickner 2020a, 108-109).
The master patient index (MPI) manager has identified a pattern of duplicate health record numbers
from the specimen processing area of the hospital. The MPI manager merged the patient information
and corrected the duplicates in the patient information system. After this merging process, which
department should the MPI manager notify to correct the source system data?
Laboratory
Radiology
Quality Management
Registration
Laboratory
Feedback: As the HIM department merges two duplicates together, the source system (laboratory) also
must be corrected. This creates new challenges for organizations because merge functionality could be
different in each system or module, which in turn creates data redundancy. When duplicates are
identified, the department managers need to be notified. Addressing ongoing errors within the MPI
