RHIA Health Data Content and Structure 1

Question 1

Which health record documentation standard requires that every entry be authenticated by the responsible provider?

Accepted Answer

CMS Conditions of Participation

Answer

Joint Commission standard

Answer

HL7 specification

Answer

HIPAA Privacy Rule

Question 2

What is the primary purpose of the master patient index (MPI) in a healthcare facility?

Accepted Answer

Uniquely identify and track each patient across encounters

Answer

Store clinical documentation

Answer

Assign diagnosis codes

Answer

Manage insurance billing

Question 3

Which data element in a health record is used to link all encounters for a single patient within a facility?

Accepted Answer

Medical record number (MRN)

Answer

Encounter number

Answer

Account number

Answer

Social Security Number

Question 4

Which section of the acute care health record is legally required to be completed within 24 hours of admission?

Accepted Answer

History and physical (H&P)

Answer

Discharge summary

Answer

Operative report

Answer

Consultation report

Question 5

What does the term 'legal health record' define?

Accepted Answer

The subset of health information disclosed in response to legal requests

Answer

Records subpoenaed by a court

Answer

All records stored in the EHR system

Answer

Records signed by an attorney

Question 6

In health information management, what is the purpose of a deficiency analysis?

Accepted Answer

Identify incomplete or missing health record documentation

Answer

Audit coding accuracy

Answer

Review patient safety incidents

Answer

Assess physician credentialing