RHIT Practice Domain 1: Data Content, Structure, and Information

Which of the following concepts includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation?

• Data accuracy

• Data completeness

• Data reliability

• Data integrity

Which of the following is a key feature of a problem-oriented health record?

• Chronological list of solved problems

• Itemized list of patient’s present and past conditions

• Itemized list of patient’s present conditions

• Sequential list of patient’s confirmed diagnoses

When managing the master patient index (MPI) which of the following would be the biggest concern for the health information technician?

• Physical space to house the server

• Maintaining the database

• Number of computers in registration

• Duplicate health record numbers

Why is only the most current version of a document displayed?

• All previous versions are deleted

• The user decides which version to see

• To ensure there is no confusion on the correct document

• Only the physician has access to previous versions of a document

HIM professionals working with a hybrid record often find this record format challenging because:

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a:

• Prospective review

• Concurrent review

• Peer review

• Retrospective review

What does a healthcare organization create when it has a unique numbering system to identify all forms used within the organization?

• Forms numbering and tracking system

• Forms distribution system

• Forms quality management system

• Forms standardization system

The information collected within a healthcare organization during the normal day-to-day operations that support patient care and business operations is known as which of the following?

• Data assets

• Information elements

• Data elements

• Information assets

Which information system provides the ability for a patient to schedule appointments or request medication refills from their provider?

• Patient portal

• Social media

• Remote patient monitoring

• Patient index

Where in an acute-care health record would the documentation “Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN.” be found?

• History and Physical

• Pathology report

• Physician order

• Laboratory report