Health Data Content and Structure Flashcards
6 cards from real RHIA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Data Content and Structure flashcards as text
Which standard governs the electronic exchange of clinical health information between systems in the US?
Answer: HL7 FHIR
HL7 FHIR (Fast Healthcare Interoperability Resources) is the current leading standard for electronic clinical health information exchange in the US.
What is the difference between structured and unstructured data in electronic health records?
Answer: Structured data uses predefined fields; unstructured includes free-text narratives
Structured data uses predefined fields and formats (like checkboxes or coded values), while unstructured data includes free-text narratives such as clinical notes.
Which document serves as the primary source for ICD-10-CM diagnosis code assignment for inpatient records?
Answer: Discharge summary
The discharge summary provides the physician's final assessment of the patient's conditions, making it the primary source for inpatient diagnosis code assignment.
What is the purpose of a retention schedule for health records?
Answer: Establish how long records must be kept before destruction
A retention schedule establishes the minimum time health records must be retained before they can be legally and safely destroyed.
What type of health record format organizes documentation by care provider discipline?
Answer: Source-oriented medical record
The source-oriented medical record organizes documentation by the discipline or department that created it, such as nursing notes, physician notes, and lab reports kept separately.
Which component of the problem-oriented medical record (POMR) lists all active diagnoses and conditions?
Answer: Problem list
The problem list is a central component of the POMR that catalogs all active diagnoses, chronic conditions, and significant past problems for ongoing reference.