RHIT Domain 1&2 EXAM PREP TEST BANK
RHIT DOMAIN 1&2 EXAM PREP TEST BANK LATEST 2025/2026
ACTUAL EXAM COMPLETE 350 QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES GRADED A+
GUARANTEED PASS- ACE YOUR EXAM
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 - Correct
Answer-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).
1|Page
, RHIT Domain 1&2 EXAM PREP TEST BANK
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 - Correct
Answer-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 - Correct Answer-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).
2|Page
, RHIT Domain 1&2 EXAM PREP TEST BANK
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 - Correct Answer-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 - Correct Answer-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).
3|Page
, RHIT Domain 1&2 EXAM PREP TEST BANK
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 - Correct Answer-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 - Correct Answer-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).
4|Page
RHIT DOMAIN 1&2 EXAM PREP TEST BANK LATEST 2025/2026
ACTUAL EXAM COMPLETE 350 QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES GRADED A+
GUARANTEED PASS- ACE YOUR EXAM
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 - Correct
Answer-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).
1|Page
, RHIT Domain 1&2 EXAM PREP TEST BANK
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 - Correct
Answer-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 - Correct Answer-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).
2|Page
, RHIT Domain 1&2 EXAM PREP TEST BANK
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 - Correct Answer-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 - Correct Answer-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).
3|Page
, RHIT Domain 1&2 EXAM PREP TEST BANK
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 - Correct Answer-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 - Correct Answer-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).
4|Page
