RHIT Record Content Management 2

Question 1

Which document in the health record serves as the primary source of diagnosis and procedure codes for billing?

Accepted Answer

Discharge summary

Answer

Nursing assessment

Answer

Operative report

Answer

Consultation note

Question 2

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?

Accepted Answer

Query the attending physician to clarify the discrepancy

Answer

Correct the nursing note to match the physician's note

Answer

Use the physician's note since it supersedes nursing documentation

Answer

Flag the record and delay coding until resolved

Question 3

Under HIPAA, which of the following is NOT considered protected health information (PHI)?

Accepted Answer

De-identified data with all 18 identifiers removed

Answer

Patient's date of birth linked to a diagnosis

Answer

Patient's geographic region smaller than a state

Answer

Patient's medical record number

Question 4

What is the purpose of a deficiency analysis in health information management?

Accepted Answer

To identify incomplete records requiring physician completion

Answer

To audit coding accuracy after discharge

Answer

To review records for potential fraud

Answer

To assess the quality of nursing documentation

Question 5

Which retention schedule applies to the health records of minor patients in most states?

Accepted Answer

Records must be retained until the patient reaches the age of majority plus the standard retention period

Answer

Records must be retained for 7 years from date of service

Answer

Records are destroyed when the patient turns 18

Answer

Minor records follow the same 10-year retention as adult records

Question 6

An electronic health record system automatically timestamps all entries. What is the primary benefit of this feature for record integrity?

Accepted Answer

It establishes a verifiable audit trail for documentation

Answer

It speeds up the coding process

Answer

It eliminates the need for physician signatures

Answer

It reduces storage costs for the facility

Question 7

Which of the following best describes a hybrid health record?

Accepted Answer

A record that contains both paper and electronic components

Answer

A record stored on two separate servers for redundancy

Answer

A record accessible by both inpatient and outpatient providers

Answer

A record that uses two different EHR vendor systems