RHIA Exam Terms with 100% Correct
Answers
Data capture: - ANS-the process of recording healthcare-related data in a health record
system or clinical database
Data cleansing - ANS-The process of detecting, diagnosing, and editing faulty data
DEEDS - ANS-Data Elements for Emergency Department Systems: a data set designed
to support the uniform collection of information in hospital-based emergency
departments
Breach notification: - ANS-HITECH Act Rule that requires both HIPAA-covered entities
and business associates to identify unsecured PHI breaches and notify the involved
parties of the breach
Content validity - ANS-The extent to which an instrument's items represent the content
that the instrument is intended to measure
ICD-9-CM: - ANS-A classification system used in the US to report morbidity and
mortality information
ICD-10-CM - ANS-Coding classification system that has replaced ICD-9-CM. Provides
the ability to code with a greater level of specifity
Incident report - ANS-A quality/performance management tool used to collect data and
information about potentially compensable events
ICNP - ANS-International classification for nursing practice; unified nursing language
system into which existing terminologies can be cross-mapped
ICD-O-3 - ANS-International Classification of Diseases for Oncology, 3rd revision; a
classification system used for reporting incidence of malignant disease
ICD-10-PCS - ANS-International classification of diseases, 10th revision, Procedure
coding system; a new procedural coding system to replace the tabular list of procedures
Legal health record - ANS-The subset of all patient-specific data created or
accumulated by a healthcare provider that may be released to third parties in response
to legally permissible requests
, Licensure - ANS-The legal authority or formal permission from authorities to carry on
certain activities that by law or regulation require such permission.
LOINC - ANS-Logical Observation Identifier Names and Codes; a database protocol
developed by the Regenstrief Institute for Heaalth Care aimed at standardizing
laboratory and clinical codes for use in clinical care, outcomes mangement and
research
Many-to-many relationship: - ANS-The concept that multiple instances of an entity may
be associated with multiple instances of another entity
MPI - ANS-Master Patient Index; a list or database created and maintained by the
healthcare facility to record the name and identification number for every patient who
has ever been admitted or treated in the facility
Medicaid - ANS-An entitlement program that oversees medical assistance for
individuals and families with low incomes and limited resources; jointly funded between
state and federal government
Medicare - ANS-A federally funded health program established in 1965 to assist with
the medical care costs of Americans 65 years of age or older as well as other
individuals entitled to Social Security benefits owning to their disabilities
Mentor: - ANS-An adviser; an experienced individual who coaches other individuals who
is at the beginning stages of his or her careers
Medication reconcilliation - ANS-Checking medications each time a patient transfers to
another level of care
Metadata - ANS-Descriptive data that characterize other data to create a clearer
understanding of their meaning and to achieve greater reliability and quality of
information
Minimum Data Set - ANS-The instrument specified by CMS that requires nursing
facilities to conduct a comprehensive, accurate, standardized, reproducible assessment
of each resident's functional capacity
Nomenclature - ANS-A recognized system of terms used in a science or an art form that
follows pre-established naming conventions; a disease nomenclature is a listing of the
proper name for each disease entity with its specific code number
NEC - ANS-Not Elsewhere classified; indicates that you have more information but no
place to put it; also means that any additional information will be lost Revere if it s
assigned the NEC label
Answers
Data capture: - ANS-the process of recording healthcare-related data in a health record
system or clinical database
Data cleansing - ANS-The process of detecting, diagnosing, and editing faulty data
DEEDS - ANS-Data Elements for Emergency Department Systems: a data set designed
to support the uniform collection of information in hospital-based emergency
departments
Breach notification: - ANS-HITECH Act Rule that requires both HIPAA-covered entities
and business associates to identify unsecured PHI breaches and notify the involved
parties of the breach
Content validity - ANS-The extent to which an instrument's items represent the content
that the instrument is intended to measure
ICD-9-CM: - ANS-A classification system used in the US to report morbidity and
mortality information
ICD-10-CM - ANS-Coding classification system that has replaced ICD-9-CM. Provides
the ability to code with a greater level of specifity
Incident report - ANS-A quality/performance management tool used to collect data and
information about potentially compensable events
ICNP - ANS-International classification for nursing practice; unified nursing language
system into which existing terminologies can be cross-mapped
ICD-O-3 - ANS-International Classification of Diseases for Oncology, 3rd revision; a
classification system used for reporting incidence of malignant disease
ICD-10-PCS - ANS-International classification of diseases, 10th revision, Procedure
coding system; a new procedural coding system to replace the tabular list of procedures
Legal health record - ANS-The subset of all patient-specific data created or
accumulated by a healthcare provider that may be released to third parties in response
to legally permissible requests
, Licensure - ANS-The legal authority or formal permission from authorities to carry on
certain activities that by law or regulation require such permission.
LOINC - ANS-Logical Observation Identifier Names and Codes; a database protocol
developed by the Regenstrief Institute for Heaalth Care aimed at standardizing
laboratory and clinical codes for use in clinical care, outcomes mangement and
research
Many-to-many relationship: - ANS-The concept that multiple instances of an entity may
be associated with multiple instances of another entity
MPI - ANS-Master Patient Index; a list or database created and maintained by the
healthcare facility to record the name and identification number for every patient who
has ever been admitted or treated in the facility
Medicaid - ANS-An entitlement program that oversees medical assistance for
individuals and families with low incomes and limited resources; jointly funded between
state and federal government
Medicare - ANS-A federally funded health program established in 1965 to assist with
the medical care costs of Americans 65 years of age or older as well as other
individuals entitled to Social Security benefits owning to their disabilities
Mentor: - ANS-An adviser; an experienced individual who coaches other individuals who
is at the beginning stages of his or her careers
Medication reconcilliation - ANS-Checking medications each time a patient transfers to
another level of care
Metadata - ANS-Descriptive data that characterize other data to create a clearer
understanding of their meaning and to achieve greater reliability and quality of
information
Minimum Data Set - ANS-The instrument specified by CMS that requires nursing
facilities to conduct a comprehensive, accurate, standardized, reproducible assessment
of each resident's functional capacity
Nomenclature - ANS-A recognized system of terms used in a science or an art form that
follows pre-established naming conventions; a disease nomenclature is a listing of the
proper name for each disease entity with its specific code number
NEC - ANS-Not Elsewhere classified; indicates that you have more information but no
place to put it; also means that any additional information will be lost Revere if it s
assigned the NEC label
