RHIA Health Data Content and Structure 2 — Questions and Answers
Question 1: Which standard governs the electronic exchange of clinical health information between systems in the US?
- ANSI X12
- HL7 FHIR (Correct answer)
- ICD-10-CM
- UB-04
Correct answer: HL7 FHIR
HL7 FHIR (Fast Healthcare Interoperability Resources) is the current leading standard for electronic clinical health information exchange in the US.
Question 2: What is the difference between structured and unstructured data in electronic health records?
- Structured data is entered by physicians; unstructured by nurses
- Structured data uses predefined fields; unstructured includes free-text narratives (Correct answer)
- Structured data is stored in paper form; unstructured is digital
- Structured data is confidential; unstructured is public
Correct 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.
Question 3: Which document serves as the primary source for ICD-10-CM diagnosis code assignment for inpatient records?
- Physician's orders
- Discharge summary (Correct answer)
- Nursing notes
- Insurance card
Correct 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.
Question 4: What is the purpose of a retention schedule for health records?
- Define who can access patient records
- Establish how long records must be kept before destruction (Correct answer)
- Assign ownership of health data
- Set documentation completion timelines
Correct 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.
Question 5: What type of health record format organizes documentation by care provider discipline?
- Problem-oriented medical record (POMR)
- Source-oriented medical record (Correct answer)
- Integrated medical record
- Hybrid medical record
Correct 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.
Question 6: Which component of the problem-oriented medical record (POMR) lists all active diagnoses and conditions?
- SOAP note
- Problem list (Correct answer)
- Database
- Initial plan
Correct 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.
RHIA Health Data Content and Structure 2
Which standard governs the electronic exchange of clinical health information between systems in the US?