RHIT Domain 1: Questions Answers

RHIT Domain 1: Questions & Answers

Which of the following individuals would serve as a bridge between information technology and business and clinical areas while managing each key area?

• Data steward
• Systems analyst
• Data scientist
• Systems administrator

(Ans- a

Data stewards serve as the bridge between information technology, and business and clinical areas. They are assigned to manage key data areas and are responsible for tasks such as data definition and information quality activities (Johns 2015, 83).

Which of the following data sets would be most helpful in developing a hospital trauma data registry?

• DEEDS
• MDS
• OASIS
• UACDS

(Ans- a

In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records (Sharp 2016, 178; Giannangelo 2015, 255). 1 / 4

Which of the following is the best definition of a forward map in data mapping?

• Linking of two systems in the opposite direction
• Linking an older version of a code set to a newer version
• Linking a newer version of a code set to an older version
• Linking a source system to a target system

(Ans- b

In a forward map, an older version of a code set is mapped to a newer version (Amatayakul 2016, 285).

What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice?

• Degree
• Certificate
• License
• Credential

(Ans- d

Credentials are the recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners and are usually conferred by a national professional organization dedicated to a specific area of healthcare practice (Shaw and Carter 2015, 336).

A healthcare provider organization, when defining its legal health record

must:

• Assess the legal environment, system limitations, and HIE agreements
• Determine what other healthcare provider organizations are doing
• Determine if a legal health record is needed
• Only include the paper components of the health record

(Ans- a

• / 4

As part of the process to identify the legal health record, the facility should assess the legal environment, system limitations, and HIE agreements (Brickner 2016, 86-87).

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?

• Minimum Data Set
• National Commission on Correctional Health Care
• Conditions of Participation
• Outcomes and Assessment Information Set

(Ans- c

Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and thus must follow the Medicare Conditions of Participation (Brickner 2016, 84, 102).

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?

• Establish a process to review health records immediately on discharge
• Review each patient's health record concurrently to make sure that

history and physicals are present

• Retrospectively review each patient's health record to make sure that

history and physicals are present

• Write a memorandum to all physicians relating the Joint Commission

requirements for documenting history and physical examinations (Ans- b 3 / 4

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).

The patient registration department assists the HIM department in what way?

• Assigning the health record number
• Processing the healthcare claim
• Implementing the information systems used by the HIM department
• Maintaining the information systems used by the HIM department

(Ans- 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?

• Medical history
• Pathology report
• Operation report
• Physical examination

(Ans- d

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