RHIT PRACTICE EXAM PREPARATION FOR 2025/2026
COMPLETE 150 QUESTIONS AND CORRECT ANSWERS |ALREADY
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A new health information management (HIM) director has been asked by the
hospital CIO to ensure data content standards are identified, understood,
implemented, and managed for the hospital's EHR system. Which of the following
should be the HIM director's first step in carrying out this responsibility?
a. Call the EHR vendor and ask to review the system's data dictionary
b. Identify data content requirements for all areas of the organization
c. Schedule a meeting with all department directors to get their input
d. Contact CMS to determine what data sets are required to be collected
b. Identify data content requirements for all areas of the organization
Data content standards allow organizations to collect data once and use it many
times in many ways. They also assist in data storage and mining as well as
sharing data with external organizations for use in benchmarking and other
purposes.
A health data analyst has been asked to compile a report of the percentage of
patients who had a baseline partial thromboplastin time (PTT) test performed
prior to receiving heparin. What clinical reports in the health record would the
health data analyst need to consult in order to prepare this report?
a. Physician progress notes and medication record
b. Nursing and physician progress notes
c. Medication administration record and clinical laboratory reports
d. Physician orders and clinical laboratory reports
c. Medication administration record and clinical laboratory reports
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Clinical laboratory reports should be reviewed to determine if a partial
thromboplastin time (PTT) test was performed. Medication Administration
Records (MAR) should be reviewed to determine if heparin was given after the
PTT test was performed.
Which of the following is considered the authoritative resource in locating a
health record?
a. Disease index
b. Master patient index
c. Patient directory
d. Patient registry
b. Master patient index (MPI)
The master patient index (MPI) is the permanent record of all patients treated at
a healthcare facility. It is used by the HIM department to look up patient
demographics, dates of care, the patient's health record number, and other
information.
The HIM manager is conducting a study in which she is comparing the current
year's diagnosis codes to the proposed new codes for the next fiscal year and
documenting variations in order to assess the impact on the organization. This
process creates a:
a. Data chargemaster report
b. Data dictionary
c. Database management system
d. Data map
d. Data map
Data mapping is a process that allows for connections between two systems. For
example, mapping two different coding systems to show the equivalent codes
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allows for data initially captured for one purpose to be translated and used for
another purpose.
A family practitioner requests the opinion of a physician specialist who reviews
the patient's health record and examines the patient. In what type of report
would the physician specialist record findings, impressions, and
recommendations?
a. Consultation
b. Medical history
c. Physical examination
d. Progress notes
a. Consultation
The consultation report documents the clinical opinion of a physician other than
the primary or attending physician. The report is based on the consulting
physician's examination of the patient and a review of his or her health record.
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?
a. Laboratory
b. Radiology
c. Quality Management
d. Registration
a. Laboratory
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
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module, which in turn creates data redundancy. When duplicates are identified,
the department managers need to be notified. Addressing ongoing errors within
the MPI means an established quality measurement and maintenance program
is crucial to the future of healthcare.
What type of analysis compares omitted clinical information received from
external providers with the needed clinical information to make a correct
diagnosis?
a. Risk management analysis
b. Qualitative analysis
c. Gap analysis
d. Document management analysis
c. Gap analysis
The gap analysis process compares omitted clinical information received from
external providers with the needed clinical information to make a correct
diagnosis. Once complete, the HIM professional would analyze the data and
develop a plan for correction.
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?
a. Establish a process to review health records immediately on discharge
b. Review each patient's health record concurrently to ensure the history and
physicals are present
c. Retrospectively review each patient's health record to ensure the history and
physicals are present
d. Write a memorandum to all physicians relating the Joint Commission
requirements for documenting history and physical examinations
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