RHIA Health Data Content and Structure 3

Question 1

What is the minimum retention period for health records under Medicare Conditions of Participation?

Accepted Answer

5 years

Answer

3 years

Answer

7 years

Answer

10 years

Question 2

Which term describes an incomplete health record that has not been finalized within the facility's required timeframe?

Accepted Answer

Delinquent record

Answer

Deficient record

Answer

Suspended record

Answer

Pending record

Question 3

What is the purpose of abstracting data from health records?

Accepted Answer

Extracting specific data elements for databases, reporting, or analysis

Answer

Summarizing records for legal proceedings

Answer

Removing outdated information from active records

Answer

Creating abbreviated records for emergency access

Question 4

Which type of data would be found in a secondary health record but NOT a primary health record?

Accepted Answer

Aggregate statistical reports

Answer

Physician progress notes

Answer

Operative reports

Answer

Discharge summaries

Question 5

Under UHDDS guidelines, which diagnosis must be identified as the principal diagnosis for inpatient coding?

Accepted Answer

The condition established after study to be chiefly responsible for admission

Answer

The most serious condition treated

Answer

The first diagnosis listed on the physician's orders

Answer

The diagnosis associated with the highest DRG weight

Question 6

What is the role of the health information manager in a clinical documentation improvement (CDI) program?

Accepted Answer

Educate physicians on documentation to support accurate code assignment

Answer

Perform physical exams to verify diagnoses

Answer

Approve all physician orders

Answer

Audit pharmacy dispensing records