- Registered Health Information Technician Health Record Content Management Flashcards
6 cards from real RHIT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
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What is the required timeframe for completing a history and physical (H&P) for inpatient admission per The Joint Commission?
Answer: Within 24 hours of admission
The Joint Commission requires the H&P to be completed within 24 hours of inpatient admission.
Which document summarizes a patient's entire inpatient stay and must be completed at discharge?
Answer: Discharge summary
The discharge summary provides a comprehensive overview of the entire hospital stay.
What is the purpose of an informed consent document?
Answer: To document that the patient was informed of risks, benefits, alternatives and voluntarily agreed to treatment
Informed consent documents that the patient received information about the proposed treatment and voluntarily agreed.
How soon after surgery must an operative report be documented?
Answer: Immediately after surgery with a brief note, and full report within 24 hours
A brief operative note must be written immediately; the full report must be available within 24 hours.
What is the difference between authentication and authorship in health records?
Answer: Authorship identifies who created the entry while authentication confirms it through a signature
Authorship identifies who created the entry, while authentication is formally confirming and approving it.
What type of form documents the medications administered to a patient including dose, route, time, and administrator?
Answer: Medication Administration Record (MAR)
The MAR documents each medication administered including name, dose, route, time, and administrator.