Record Content Management Flashcards
7 cards from real RHIT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Record Content Management flashcards as text
Which document in the health record serves as the primary source of diagnosis and procedure codes for billing?
Answer: Discharge summary
The discharge summary synthesizes the entire encounter and is the primary source used for coding diagnoses and procedures for billing.
A patient's health record contains conflicting documentation between the physician's note and the nursing note. What is the BEST course of action for the HIM professional?
Answer: Query the attending physician to clarify the discrepancy
A physician query is the appropriate method to resolve documentation discrepancies without altering existing entries.
Under HIPAA, which of the following is NOT considered protected health information (PHI)?
Answer: De-identified data with all 18 identifiers removed
Data from which all 18 HIPAA-specified identifiers have been removed meets the de-identification standard and is not considered PHI.
What is the purpose of a deficiency analysis in health information management?
Answer: To identify incomplete records requiring physician completion
Deficiency analysis identifies missing or incomplete components of the health record that require provider completion to meet standards.
Which retention schedule applies to the health records of minor patients in most states?
Answer: Records must be retained until the patient reaches the age of majority plus the standard retention period
Most states require that minor records be retained until the patient reaches age of majority (usually 18) plus the state's standard adult retention period.
An electronic health record system automatically timestamps all entries. What is the primary benefit of this feature for record integrity?
Answer: It establishes a verifiable audit trail for documentation
Automatic timestamps create an audit trail that verifies when documentation was created or modified, supporting record integrity.
Which of the following best describes a hybrid health record?
Answer: A record that contains both paper and electronic components
A hybrid health record is one in which documentation exists in both paper and electronic formats during a transition to a fully electronic system.