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

Medicare Conditions of Participation require hospitals to retain medical records for at least 5 years from the date of discharge.

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

A delinquent record is one that remains incomplete beyond the facility's defined completion timeframe, typically 30 days post-discharge.

Question 3

What is the purpose of abstracting data from health records?

Accepted Answer

Extracting specific data elements for databases, reporting, or analysis

Answer

Abstracting involves extracting specific data elements from health records to populate databases used for reporting, research, and quality improvement.

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

Secondary records, such as aggregate statistical reports, are derived from primary patient records and used for administrative, research, or regulatory purposes.

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

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.

RHIA Exam Practice Test

RHIA Exam Practice Test

RHIA Health Data Content and Structure 3