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
What is the minimum retention period for health records under Medicare Conditions of Participation?
Answer: 5 years
Medicare Conditions of Participation require hospitals to retain medical records for at least 5 years from the date of discharge.
Which term describes an incomplete health record that has not been finalized within the facility's required timeframe?
Answer: Delinquent record
A delinquent record is one that remains incomplete beyond the facility's defined completion timeframe, typically 30 days post-discharge.
What is the purpose of abstracting data from health records?
Answer: Extracting specific data elements for databases, reporting, or analysis
Abstracting involves extracting specific data elements from health records to populate databases used for reporting, research, and quality improvement.
Which type of data would be found in a secondary health record but NOT a primary health record?
Answer: Aggregate statistical reports
Secondary records, such as aggregate statistical reports, are derived from primary patient records and used for administrative, research, or regulatory purposes.
Under UHDDS guidelines, which diagnosis must be identified as the principal diagnosis for inpatient coding?
Answer: The condition established after study to be chiefly responsible for admission
Per Uniform Hospital Discharge Data Set (UHDDS) guidelines, the principal diagnosis is the condition established after study to be chiefly responsible for causing the admission.
What is the role of the health information manager in a clinical documentation improvement (CDI) program?
Answer: Educate physicians on documentation to support accurate code assignment
In CDI programs, HIM professionals educate providers on documentation specificity to ensure coded data accurately reflects the patient's clinical condition.