RHIT - Registered Health Information Technician Health Record Content Management Questions and Answers

Question 1

A hospital's Health Information Management (HIM) department is defining its legal health record (LHR).
Which of the following should be the primary consideration when determining the content of the LHR?

Accepted Answer

The organization's own policies, in conjunction with federal regulations, state laws, and accreditation standards.

Answer

The storage capacity of the electronic health record (EHR) system.

Answer

The preferences of the hospital's primary software vendor.

Answer

The data required for marketing and fundraising purposes.

Question 2

A patient was discharged from the hospital, and the paper-based portion of their hybrid health record needs to be incorporated into the electronic system. Which process ensures that these paper documents are converted to electronic images and linked to the correct patient record?

Accepted Answer

Document imaging and indexing

Answer

Data mining

Answer

Revenue cycle management

Answer

System backup and recovery

Question 3

To ensure the integrity of a health record, an RHIT is performing a quality audit. Which of the following is a key characteristic of data quality and integrity?

Accepted Answer

Timeliness

Answer

Brevity

Answer

Complexity

Answer

Subjectivity

Question 4

A physician's office is transitioning to a new certified EHR system. To maintain the integrity of patient records, the HIM professional is tasked with managing the Master Patient Index (MPI). What is the primary function of the MPI?

Accepted Answer

To link a patient to their medical record numbers and prevent the creation of duplicate records.

Answer

To serve as the primary repository for all clinical documentation.

Answer

To process and submit all billing claims to third-party payers.

Answer

To track the physical location of all paper-based health records.

Question 5

Which of the following would NOT typically be considered part of the designated record set (DRS) as defined by HIPAA, which an organization must provide to a patient upon request?

Accepted Answer

Psychotherapy notes that are maintained separately.

Answer

Medical records and billing records.

Answer

Records used to make decisions about individuals.

Answer

Enrollment, payment, and claims adjudication records.

Question 6

During a routine chart review, an RHIT discovers that a nurse's signature is missing from a paper-based medication administration record that has already been scanned into the EHR. What is the appropriate action to take?

Accepted Answer

Follow the facility's policy for late entries or amendments to authenticate the entry.

Answer

Delete the scanned image and ask the nurse to sign a blank form.

Answer

Add a digital note to the image stating the signature is missing.

Answer

Ignore the missing signature as the record is already electronic.