RHIA Health Data Content and Structure 2

Question 1

Which standard governs the electronic exchange of clinical health information between systems in the US?

Accepted Answer

HL7 FHIR

Answer

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?

Accepted Answer

Structured data uses predefined fields; unstructured includes free-text narratives

Answer

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?

Accepted Answer

Discharge summary

Answer

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?

Accepted Answer

Establish how long records must be kept before destruction

Answer

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?

Accepted Answer

Source-oriented medical record

Answer

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.

RHIA Exam Practice Test

RHIA Exam Practice Test

RHIA Health Data Content and Structure 2