RHIT - Registered Health Information Technician Health Record Content Management 2

Question 1

What is the required timeframe for completing a history and physical (H&P) for inpatient admission per The Joint Commission?

Accepted Answer

Within 24 hours of admission

Answer

Within 48 hours

Answer

Within 72 hours

Answer

Before discharge only

Question 2

Which document summarizes a patient's entire inpatient stay and must be completed at discharge?

Accepted Answer

Discharge summary

Answer

Admission assessment

Answer

Progress note

Answer

Operative report

Question 3

What is the purpose of an informed consent document?

Accepted Answer

To document that the patient was informed of risks, benefits, alternatives and voluntarily agreed to treatment

Answer

To record insurance information

Answer

To schedule follow-up appointments

Answer

To record dietary preferences

Question 4

How soon after surgery must an operative report be documented?

Accepted Answer

Immediately after surgery with a brief note, and full report within 24 hours

Answer

Within 48 hours

Answer

Within one week

Answer

At discharge only

Question 5

What is the difference between authentication and authorship in health records?

Accepted Answer

Authorship identifies who created the entry while authentication confirms it through a signature

Answer

They are the same thing

Answer

Authentication creates the entry

Answer

Neither applies to electronic records

Question 6

What type of form documents the medications administered to a patient including dose, route, time, and administrator?

Accepted Answer

Medication Administration Record (MAR)

Answer

Physician order sheet

Answer

Nursing assessment form

Answer

Discharge summary