RHIT DOMAIN 1 EXAM PRACTICE
QUESTIONS WITH CORRECT ANSWERS +
2026/2027 LATEST UPDATE WITH
RATIONALES
Which of the following is an example of clinical data? a. Admitting diagnosis
b. Date and time of admission
c. Insurance information
d. Health record number - CORRECT ANSWER>>>>a
The health record generally contains two types of data: clinical and administrative. Clinical
data document the patient's health condition, diagnosis, and procedures performed as well as
the healthcare treatment provided. Administrative data include demographic and financial
information as well as various consents and authorizations related to the provision of care and
the handling of confidential patient information (Brickner 2016, 90).
Which of the following is an institutional user of the health record? a. A third-party payer
b. Patient
c. Physician
d. Employer - CORRECT ANSWER>>>>a
Institutional users of the health record are organizations that need access to health records in
order to accomplish their mission. These institutional users include healthcare delivery
organizations, third-party payers, medical review organizations, research organizations,
educational organizations, accreditation organizations, government licensing agencies, and
policy-making bodies (Sayles 2016b, 54-55).
204
Correct0
Page 1 of 73
,Wrong0
Unanswered204
Registered Health I
A new HIM director has been asked by the hospital CIO to ensure data content standards are
identified, understood, implemented, and managed for the hospital's planned 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 - CORRECT
ANSWER>>>>b
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. The HIM director should identify
data content requirements for all areas of the organization to ensure the data content standards
are met (Sayles and Trawick 2014, 170).
Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an EHR? a. Make
admission date a required field
b. Provide a template for entering data in the field
c. Make admission date a numeric field
d. Provide sufficient space for input of data - CORRECT ANSWER>>>>b
Templates are a cross between free text and structured data entry. The user is able to pick and
choose data that are entered frequently, thus requiring the entry of data that change from
patient to patient. Templates can be customized to meet the needs of the organization as data
needs change by physician specialty, patient type (surgical/medical/newborn), disease, and
other classification of patients. In this situation a template would provide structured data
entry for the admission date (Brinda 2016, 159-160).
Page 2 of 73
,The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15;
required field: yes; default value: none; template: none. For this data element, data integrity
would be better assured if:
a. The template was defined
b. The data type was numeric
c. The field was not required
d. The field length was longer - CORRECT ANSWER>>>>a
A pattern used in computer-based patient records to capture data in a structured manner is
called a template. One benefit of using a template is to ensure data integrity upon data entry
(Brinda 2 016, 141; Sayles and Gordon 2016, 675).
In a cancer registry, the accession number:
a. Identifies all the cases of cancer treated in a given year
b. Is the number assigned to each case as it is entered into a cancer registry
c. Identifies the pathologic diagnosis of an individual cancer
d. Is the number assigned for the diagnosis of a cancer patient that is entered into the
cancer registry treatments and at different stages of cancer - CORRECT ANSWER>>>>b
When a case is first entered in the registry, an accession number is assigned. This number
consists of the first digits of the year the patient was first seen at the facility, and the
remaining digits are assigned sequentially throughout the year. The first case in the year, for
example, might be 10-0001. The accession number may be assigned manually or by the
automated cancer database used by the organization (Sharp 2016, 176).
Why does an ideal EHR system require point-of-care charting? a. Eases duplicate data entry
burden
b. Eliminates intermediary paper forms
c. Reduces memory loss
d. Ensures that appropriate data are collected timely - CORRECT ANSWER>>>>d
Page 3 of 73
, Many hospitals begin their EHR implementation with point of care (POC) charting systems.
These systems provide context-sensitive templates. Templates ensure that the appropriate
data are collected and guide users in adhering to professional practice standards. These might
include nursing admission assessments, nursing progress notes, vital signs charting, intake
and output records, and the like (Giannangelo 2016b, 325-326).
Which of the following is the best definition of system of record (SOR)? a. Authoritative
source for data about an entity
b. Master entity application
c. Exact match logic
d. Primary data about an entity - CORRECT ANSWER>>>>a
Once the organization identifies sources, it lists the most trusted ones. Usually these are the
sources with the most volume of master data records associated with a specific entity. In
some instances, the master data will have their own unique system of record. A system of
record is usually a specialized application system and the authoritative source for data about
an entity (Johns 2015, 175).
A family practitioner requests the opinion of a physician specialist who reviews the patient's
health record and examines the patient. The physician specialist would record findings,
impressions, and recommendations in what type of report? a. Consultation
b. Medical history
c. Physical examination
d. Progress notes - CORRECT ANSWER>>>>a
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 (Brickner 2016, 96).
Which of the following is the goal of the quantitative analysis performed by HIM
professionals? a. Ensuring that the health record is legible
b. Verifying that health professionals are providing appropriate care
c. Identifying deficiencies early so they can be corrected
Page 4 of 73
QUESTIONS WITH CORRECT ANSWERS +
2026/2027 LATEST UPDATE WITH
RATIONALES
Which of the following is an example of clinical data? a. Admitting diagnosis
b. Date and time of admission
c. Insurance information
d. Health record number - CORRECT ANSWER>>>>a
The health record generally contains two types of data: clinical and administrative. Clinical
data document the patient's health condition, diagnosis, and procedures performed as well as
the healthcare treatment provided. Administrative data include demographic and financial
information as well as various consents and authorizations related to the provision of care and
the handling of confidential patient information (Brickner 2016, 90).
Which of the following is an institutional user of the health record? a. A third-party payer
b. Patient
c. Physician
d. Employer - CORRECT ANSWER>>>>a
Institutional users of the health record are organizations that need access to health records in
order to accomplish their mission. These institutional users include healthcare delivery
organizations, third-party payers, medical review organizations, research organizations,
educational organizations, accreditation organizations, government licensing agencies, and
policy-making bodies (Sayles 2016b, 54-55).
204
Correct0
Page 1 of 73
,Wrong0
Unanswered204
Registered Health I
A new HIM director has been asked by the hospital CIO to ensure data content standards are
identified, understood, implemented, and managed for the hospital's planned 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 - CORRECT
ANSWER>>>>b
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. The HIM director should identify
data content requirements for all areas of the organization to ensure the data content standards
are met (Sayles and Trawick 2014, 170).
Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an EHR? a. Make
admission date a required field
b. Provide a template for entering data in the field
c. Make admission date a numeric field
d. Provide sufficient space for input of data - CORRECT ANSWER>>>>b
Templates are a cross between free text and structured data entry. The user is able to pick and
choose data that are entered frequently, thus requiring the entry of data that change from
patient to patient. Templates can be customized to meet the needs of the organization as data
needs change by physician specialty, patient type (surgical/medical/newborn), disease, and
other classification of patients. In this situation a template would provide structured data
entry for the admission date (Brinda 2016, 159-160).
Page 2 of 73
,The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15;
required field: yes; default value: none; template: none. For this data element, data integrity
would be better assured if:
a. The template was defined
b. The data type was numeric
c. The field was not required
d. The field length was longer - CORRECT ANSWER>>>>a
A pattern used in computer-based patient records to capture data in a structured manner is
called a template. One benefit of using a template is to ensure data integrity upon data entry
(Brinda 2 016, 141; Sayles and Gordon 2016, 675).
In a cancer registry, the accession number:
a. Identifies all the cases of cancer treated in a given year
b. Is the number assigned to each case as it is entered into a cancer registry
c. Identifies the pathologic diagnosis of an individual cancer
d. Is the number assigned for the diagnosis of a cancer patient that is entered into the
cancer registry treatments and at different stages of cancer - CORRECT ANSWER>>>>b
When a case is first entered in the registry, an accession number is assigned. This number
consists of the first digits of the year the patient was first seen at the facility, and the
remaining digits are assigned sequentially throughout the year. The first case in the year, for
example, might be 10-0001. The accession number may be assigned manually or by the
automated cancer database used by the organization (Sharp 2016, 176).
Why does an ideal EHR system require point-of-care charting? a. Eases duplicate data entry
burden
b. Eliminates intermediary paper forms
c. Reduces memory loss
d. Ensures that appropriate data are collected timely - CORRECT ANSWER>>>>d
Page 3 of 73
, Many hospitals begin their EHR implementation with point of care (POC) charting systems.
These systems provide context-sensitive templates. Templates ensure that the appropriate
data are collected and guide users in adhering to professional practice standards. These might
include nursing admission assessments, nursing progress notes, vital signs charting, intake
and output records, and the like (Giannangelo 2016b, 325-326).
Which of the following is the best definition of system of record (SOR)? a. Authoritative
source for data about an entity
b. Master entity application
c. Exact match logic
d. Primary data about an entity - CORRECT ANSWER>>>>a
Once the organization identifies sources, it lists the most trusted ones. Usually these are the
sources with the most volume of master data records associated with a specific entity. In
some instances, the master data will have their own unique system of record. A system of
record is usually a specialized application system and the authoritative source for data about
an entity (Johns 2015, 175).
A family practitioner requests the opinion of a physician specialist who reviews the patient's
health record and examines the patient. The physician specialist would record findings,
impressions, and recommendations in what type of report? a. Consultation
b. Medical history
c. Physical examination
d. Progress notes - CORRECT ANSWER>>>>a
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 (Brickner 2016, 96).
Which of the following is the goal of the quantitative analysis performed by HIM
professionals? a. Ensuring that the health record is legible
b. Verifying that health professionals are providing appropriate care
c. Identifying deficiencies early so they can be corrected
Page 4 of 73
