RHIT Certification Practice Test 1 – 150
Q&A
BukayoSaka120
d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific
items on every inpatient. - correct answer ✔✔A health record technician has been asked to
review the discharge patient abstracting module of a proposed new electronic health record
(EHR). Which of the following data sets would the technician consult to ensure the system
collects all federally required discharge data elements for Medicare and Medicaid inpatients in
an acute-care hospital?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS
d. Vocabulary standards
Vocabulary standards are a list or collection of clinical words or phrases with their meanings;
also, the set of words used by an individual or group within a particular subject field, such as to
provide consistent descriptions of medical terms for an individual's condition in the health
record. - correct answer ✔✔Standardizing medical terminology to avoid differences in naming
various health conditions and procedures (such as the synonyms bunionectomy, McBride
procedure, and repair of hallux valgus) is one purpose of:
,a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards
b. Evaluate patterns and trends of patient care
BukayoSaka120
Patient care managers are responsible for the overall evaluation of services rendered for their
particular area of responsibility. To identify patterns and trends, they take details from individual
health records and put all the information together in one place. - correct answer ✔✔Patient
care managers use the data documented in the health record to:
a. Determine the extent and effects of occupational hazards
b. Evaluate patterns and trends of patient care
c. Generate patient bills and third-party payer claims for reimbursement
d. Provide direct patient care
b. Data consistency
Consistency means ensuring the patient data is reliable and the same across the entire patient
encounter. In other words, patient data within the record should be the same and should not
contradict other data also in the patient record. - correct answer ✔✔At admission, Mrs. Smith's
date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the
date of birth are transposed in reports. This situation reflects a problem in:
,a. Data comprehensiveness
b. Data consistency
c. Data currency
d. Data granularity
a. Vital signs record
BukayoSaka120
The vital signs record is comprised of blood pressure readings, temperature, respiration, and
pulse, making it the best source to gather this type of information. - correct answer ✔✔A health
data analyst has been asked to compile a listing of daily blood pressure readings for patients
with a diagnosis of hypertension who were treated on the medical unit within a two-week
period. What clinical report would be the best source to gather this information?
a. Vital signs record
b. Initial nursing assessment record
c. Physician progress notes
d. Admission record
d. Uses an itemized list of the patient's past and present health problems
The problem-oriented health record is better suited to serve the patient and the end user of the
patient's information. The key characteristic of this format is an itemized list of the patient's
past and present social, psychological, and health problems. - correct answer ✔✔Which of the
following is a key characteristic of the problem-oriented health record?
, a. Allows all providers to document in the health record
b. Uses laboratory reports and other diagnostic tools to determine health problems
c. Provides electronic documentation in the health record
d. Uses an itemized list of the patient's past and present health problems
b. The diseases to be reported are established by state law.
c. BukayoSaka120
All states have a health department with a division that is required to track and record
communicable diseases. When a patient is diagnosed with one of the diseases from the health
department's communicable disease list, the facility must notify the state public health
department. - correct answer ✔✔Which of the following is true regarding the reporting of
communicable diseases?
a. They must be reported by the patient to the health department.
b. The diseases to be reported are established by state law.
c. The diseases to be reported are established by HIPAA.
d. They are never reported because it would violate the patient's privacy.
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. - correct answer ✔✔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?
Q&A
BukayoSaka120
d. UHDDS (Uniform Hospital Discharge Data Set)
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific
items on every inpatient. - correct answer ✔✔A health record technician has been asked to
review the discharge patient abstracting module of a proposed new electronic health record
(EHR). Which of the following data sets would the technician consult to ensure the system
collects all federally required discharge data elements for Medicare and Medicaid inpatients in
an acute-care hospital?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS
d. Vocabulary standards
Vocabulary standards are a list or collection of clinical words or phrases with their meanings;
also, the set of words used by an individual or group within a particular subject field, such as to
provide consistent descriptions of medical terms for an individual's condition in the health
record. - correct answer ✔✔Standardizing medical terminology to avoid differences in naming
various health conditions and procedures (such as the synonyms bunionectomy, McBride
procedure, and repair of hallux valgus) is one purpose of:
,a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards
b. Evaluate patterns and trends of patient care
BukayoSaka120
Patient care managers are responsible for the overall evaluation of services rendered for their
particular area of responsibility. To identify patterns and trends, they take details from individual
health records and put all the information together in one place. - correct answer ✔✔Patient
care managers use the data documented in the health record to:
a. Determine the extent and effects of occupational hazards
b. Evaluate patterns and trends of patient care
c. Generate patient bills and third-party payer claims for reimbursement
d. Provide direct patient care
b. Data consistency
Consistency means ensuring the patient data is reliable and the same across the entire patient
encounter. In other words, patient data within the record should be the same and should not
contradict other data also in the patient record. - correct answer ✔✔At admission, Mrs. Smith's
date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the
date of birth are transposed in reports. This situation reflects a problem in:
,a. Data comprehensiveness
b. Data consistency
c. Data currency
d. Data granularity
a. Vital signs record
BukayoSaka120
The vital signs record is comprised of blood pressure readings, temperature, respiration, and
pulse, making it the best source to gather this type of information. - correct answer ✔✔A health
data analyst has been asked to compile a listing of daily blood pressure readings for patients
with a diagnosis of hypertension who were treated on the medical unit within a two-week
period. What clinical report would be the best source to gather this information?
a. Vital signs record
b. Initial nursing assessment record
c. Physician progress notes
d. Admission record
d. Uses an itemized list of the patient's past and present health problems
The problem-oriented health record is better suited to serve the patient and the end user of the
patient's information. The key characteristic of this format is an itemized list of the patient's
past and present social, psychological, and health problems. - correct answer ✔✔Which of the
following is a key characteristic of the problem-oriented health record?
, a. Allows all providers to document in the health record
b. Uses laboratory reports and other diagnostic tools to determine health problems
c. Provides electronic documentation in the health record
d. Uses an itemized list of the patient's past and present health problems
b. The diseases to be reported are established by state law.
c. BukayoSaka120
All states have a health department with a division that is required to track and record
communicable diseases. When a patient is diagnosed with one of the diseases from the health
department's communicable disease list, the facility must notify the state public health
department. - correct answer ✔✔Which of the following is true regarding the reporting of
communicable diseases?
a. They must be reported by the patient to the health department.
b. The diseases to be reported are established by state law.
c. The diseases to be reported are established by HIPAA.
d. They are never reported because it would violate the patient's privacy.
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. - correct answer ✔✔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?
