Registered Health Information Technician Flashcards

A health information technician discovers that two different medical record numbers have been assigned to the same patient. What is this error called?

Answer: Duplicate

When the same patient is assigned two or more medical record numbers, it is called a duplicate.

What is the primary function of the Uniform Hospital Discharge Data Set (UHDDS)?

Answer: To define a minimum set of data elements collected at discharge for inpatient stays

The UHDDS defines the core minimum data elements that should be collected for every inpatient hospital discharge.

Which of the following best describes the concept of data integrity in health information management?

Answer: Data is accurate, consistent, and reliable throughout its lifecycle

Data integrity refers to the accuracy, consistency, and reliability of data throughout its entire lifecycle.

What does the term 'legal health record' refer to in a healthcare organization?

Answer: The official business record of patient care that the organization would produce in response to legal proceedings

The legal health record is the subset of all patient information that constitutes the organization's official business record.

A RHIT is reviewing records and notices a physician documented 'CHF' without further specification. What action should the CDI specialist take?

Answer: Query the physician for the type and acuity of heart failure

The CDI specialist should query the physician to obtain documentation of the specific type and acuity of heart failure.

What is the purpose of a Notice of Privacy Practices (NPP) under HIPAA?

Answer: To inform patients about how their PHI may be used and their rights regarding their information

The Notice of Privacy Practices informs patients about how the covered entity may use and disclose their PHI and their rights.