RHIA Domain 1| 334 Question| WITH
COMPLETE SOLUTION
Data mapping is used to harmonize data sets or code sets. The code or data set from which the
map originates is the: Correct Answer: Source
For the purposes of mapping, the term coding system is used very broadly to include? Correct
Answer: classification, terminology, and other data representation systems.
Mapping is necessary as health information systems and their use evolves in order to? Correct
Answer: link disparate systems and data sets.
Who owns the health records of patients treated in a healthcare facility? Correct Answer: The
facility
Health records and other documentation related to patient care are the property of the? Correct
Answer: hospital or healthcare provider that created them.
In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be
dosed in milligrams. Which dimension of data quality is being applied in this situation? Correct
Answer: Precision
Precision often relates to? Correct Answer: numerical data.
Using the staff turnover information in the following graph, determine the next action the quality
council at the hospital should take. Correct Answer: Coordinate a PI team to look into the cause
for the high employee turnover rate in year 3
The health information management (HIM) manager is concerned with a backlog in transcription
of surgical reports. The medical staff rules and regulations stipulate that the surgeon should:
Correct Answer: Write a detailed postoperative progress note about the procedure performed
The operative report should be written or dictated immediately after? Correct Answer: surgery
and filed in the patient's health record as soon as possible.
One member of the medical staff reviewed a patient's history, examined the patient, and wrote
findings and recommendations at the request of another member of the medical staff. The
resulting medical report that documents the response of the reviewing medical staff member is a:
Correct Answer: Consultation report
A consultation report is the documented findings or recommendation for further treatment by a?
Correct Answer: physician or specialist.
The Abbreviated Injury Scale is a data element recorded in which of the following registries?
Correct Answer: Trauma
,The Abbreviated Injury Scale reflects that nature of the injury and the severity (threat to life) by?
Correct Answer: body system.
Which of the following would a data analyst use to locate, retrieve, and use data? Correct
Answer: Metadata
In establishing roles and responsibilities within a data governance program, which of the
following would normally be embedded within an organization's business unit and be
responsible for monitoring the data quality of the unit? Correct Answer: Data steward
Data stewards are typically designated throughout the? Correct Answer: enterprise within
business units, including IT
The director of the health information department wanted to determine the level of physicians'
satisfaction with the department's services. The director surveyed the physicians who came to the
department. What type of sample is this? Correct Answer: Convenience
Researchers use convenience samples when they "conveniently" use? Correct Answer: any unit
that is at hand.
Who is responsible for the content, quality, and authentication of the discharge summary?
Correct Answer: Attending physician
Under which circumstances may an updated entry be added to a patient's health record in place
of a complete history and physical? Correct Answer: When the patient is readmitted within 30
days of the initial treatment for the same condition
An updated entry may be used for the patient's history and physical when the patient is
readmitted within Correct Answer: 30 days of the initial treatment for the same condition
The HIM director wants to ensure that state regulations are being followed with regard to
retention of the health records of minors. Which of the following data management domains
would be responsible for ensuring these regulations are followed? Correct Answer: Data life
cycle management
Data management is based on the assumption that all data have a? Correct Answer: life cycle.
Typical data life cycle functions requiring data governance include: Correct Answer:
establishing what data are to be collected and how they are to be captured; setting standards for
data retention and storage; determining processes for data access and distribution; establishing
standards for data archival and destruction.
General Hospital is performing peer reviews of its medical providers for quality outcomes of
care. The hospital has over 500 providers on its medical staff. The process to review even 10
cases for each provider is quite extensive. The quality department has concluded that, to
, accomplish this review process, it will review 20 percent of each provider's inpatient admissions
to the hospital on an every-other-year rotation. In this situation, the quality department has
applied which of the following techniques to its review process? Correct Answer: Sampling
Sometimes, the organizational characteristic or parameter about which data are being collected
occurs too frequently to? Correct Answer: measure every occurrence.
The clinical statement "microscopic sections of the gallbladder reveal a surface lined by tall
columnar cells of uniform size and shape" would be documented on which health record form?
Correct Answer: Pathology report
A pathology report is a document that contains the diagnosis determined by examining cells and
tissues under a? Correct Answer: microscope.
Standardizing medical terminology to avoid differences in naming various medical conditions
and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux
valgus) is one purpose of: Correct Answer: Vocabulary standards
A vocabulary standard is a common definition for? Correct Answer: medical terms to encourage
consistent descriptions of an individual's condition in the health record
As part of the initiative to improve data integrity, the Data Quality Committee conducted an
inventory of all the hospital's databases. The review showed that more than 70 percent of the
identified databases did not have data dictionaries. Given this data, what should be the
committee's first action? Correct Answer: Establish a data dictionary policy with associated
standards
What relationships is the following entity relationship diagram showing? Correct Answer: Each
division has one hospital, but each hospital has many divisions.
Sue Smith has been admitted to Healthwise Hospital with stroke symptoms. Which professionals
on her healthcare team are primarily responsible for documenting diagnosis and treatment
information in her record during her hospital stay? Correct Answer: Dr. Helms, her primary
physician; and other providers on her care team
A data element such as "date of birth" in a database is considered which of the following?
Correct Answer: Structured data
Structured data commonly refer to data that are organized and easily retrievable and interpreted
by? Correct Answer: traditional databases and data models?
As part of his role at the local hospital, Jake is reviewing Joint Commission standards to ensure
that the organization is meeting the accreditation requirements. As part of the review, Jake is
looking at a specific set of standards that are primarily focused on documentation. Some of the
standard requirements include care provided, procedures that were done on the patient, and the
COMPLETE SOLUTION
Data mapping is used to harmonize data sets or code sets. The code or data set from which the
map originates is the: Correct Answer: Source
For the purposes of mapping, the term coding system is used very broadly to include? Correct
Answer: classification, terminology, and other data representation systems.
Mapping is necessary as health information systems and their use evolves in order to? Correct
Answer: link disparate systems and data sets.
Who owns the health records of patients treated in a healthcare facility? Correct Answer: The
facility
Health records and other documentation related to patient care are the property of the? Correct
Answer: hospital or healthcare provider that created them.
In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be
dosed in milligrams. Which dimension of data quality is being applied in this situation? Correct
Answer: Precision
Precision often relates to? Correct Answer: numerical data.
Using the staff turnover information in the following graph, determine the next action the quality
council at the hospital should take. Correct Answer: Coordinate a PI team to look into the cause
for the high employee turnover rate in year 3
The health information management (HIM) manager is concerned with a backlog in transcription
of surgical reports. The medical staff rules and regulations stipulate that the surgeon should:
Correct Answer: Write a detailed postoperative progress note about the procedure performed
The operative report should be written or dictated immediately after? Correct Answer: surgery
and filed in the patient's health record as soon as possible.
One member of the medical staff reviewed a patient's history, examined the patient, and wrote
findings and recommendations at the request of another member of the medical staff. The
resulting medical report that documents the response of the reviewing medical staff member is a:
Correct Answer: Consultation report
A consultation report is the documented findings or recommendation for further treatment by a?
Correct Answer: physician or specialist.
The Abbreviated Injury Scale is a data element recorded in which of the following registries?
Correct Answer: Trauma
,The Abbreviated Injury Scale reflects that nature of the injury and the severity (threat to life) by?
Correct Answer: body system.
Which of the following would a data analyst use to locate, retrieve, and use data? Correct
Answer: Metadata
In establishing roles and responsibilities within a data governance program, which of the
following would normally be embedded within an organization's business unit and be
responsible for monitoring the data quality of the unit? Correct Answer: Data steward
Data stewards are typically designated throughout the? Correct Answer: enterprise within
business units, including IT
The director of the health information department wanted to determine the level of physicians'
satisfaction with the department's services. The director surveyed the physicians who came to the
department. What type of sample is this? Correct Answer: Convenience
Researchers use convenience samples when they "conveniently" use? Correct Answer: any unit
that is at hand.
Who is responsible for the content, quality, and authentication of the discharge summary?
Correct Answer: Attending physician
Under which circumstances may an updated entry be added to a patient's health record in place
of a complete history and physical? Correct Answer: When the patient is readmitted within 30
days of the initial treatment for the same condition
An updated entry may be used for the patient's history and physical when the patient is
readmitted within Correct Answer: 30 days of the initial treatment for the same condition
The HIM director wants to ensure that state regulations are being followed with regard to
retention of the health records of minors. Which of the following data management domains
would be responsible for ensuring these regulations are followed? Correct Answer: Data life
cycle management
Data management is based on the assumption that all data have a? Correct Answer: life cycle.
Typical data life cycle functions requiring data governance include: Correct Answer:
establishing what data are to be collected and how they are to be captured; setting standards for
data retention and storage; determining processes for data access and distribution; establishing
standards for data archival and destruction.
General Hospital is performing peer reviews of its medical providers for quality outcomes of
care. The hospital has over 500 providers on its medical staff. The process to review even 10
cases for each provider is quite extensive. The quality department has concluded that, to
, accomplish this review process, it will review 20 percent of each provider's inpatient admissions
to the hospital on an every-other-year rotation. In this situation, the quality department has
applied which of the following techniques to its review process? Correct Answer: Sampling
Sometimes, the organizational characteristic or parameter about which data are being collected
occurs too frequently to? Correct Answer: measure every occurrence.
The clinical statement "microscopic sections of the gallbladder reveal a surface lined by tall
columnar cells of uniform size and shape" would be documented on which health record form?
Correct Answer: Pathology report
A pathology report is a document that contains the diagnosis determined by examining cells and
tissues under a? Correct Answer: microscope.
Standardizing medical terminology to avoid differences in naming various medical conditions
and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux
valgus) is one purpose of: Correct Answer: Vocabulary standards
A vocabulary standard is a common definition for? Correct Answer: medical terms to encourage
consistent descriptions of an individual's condition in the health record
As part of the initiative to improve data integrity, the Data Quality Committee conducted an
inventory of all the hospital's databases. The review showed that more than 70 percent of the
identified databases did not have data dictionaries. Given this data, what should be the
committee's first action? Correct Answer: Establish a data dictionary policy with associated
standards
What relationships is the following entity relationship diagram showing? Correct Answer: Each
division has one hospital, but each hospital has many divisions.
Sue Smith has been admitted to Healthwise Hospital with stroke symptoms. Which professionals
on her healthcare team are primarily responsible for documenting diagnosis and treatment
information in her record during her hospital stay? Correct Answer: Dr. Helms, her primary
physician; and other providers on her care team
A data element such as "date of birth" in a database is considered which of the following?
Correct Answer: Structured data
Structured data commonly refer to data that are organized and easily retrievable and interpreted
by? Correct Answer: traditional databases and data models?
As part of his role at the local hospital, Jake is reviewing Joint Commission standards to ensure
that the organization is meeting the accreditation requirements. As part of the review, Jake is
looking at a specific set of standards that are primarily focused on documentation. Some of the
standard requirements include care provided, procedures that were done on the patient, and the
