RHIA Health Data Content and Structure

Question 1

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

Accepted Answer

CMS Conditions of Participation

Answer

CMS Conditions of Participation mandate that all health record entries be authenticated by the provider responsible for the care documented.

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

The MPI serves as the definitive source for uniquely identifying and tracking every patient across all visits and departments within a facility.

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

The medical record number (MRN) is the permanent identifier assigned to a patient that links all encounters within a facility.

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

The history and physical must be completed within 24 hours of admission (or 30 days before) per Joint Commission standards.

Question 5

What does the term 'legal health record' define?

Accepted Answer

The subset of health information disclosed in response to legal requests

Answer

The legal health record is the organization-defined subset of health information that is disclosed in response to legal requests such as subpoenas.

RHIA Exam Practice Test