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

The discharge summary synthesizes the entire encounter and is the primary source used for coding diagnoses and procedures for billing.

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

A physician query is the appropriate method to resolve documentation discrepancies without altering existing entries.

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

Data from which all 18 HIPAA-specified identifiers have been removed meets the de-identification standard and is not considered PHI.

Question 4

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

Accepted Answer

To identify incomplete records requiring physician completion

Answer

Deficiency analysis identifies missing or incomplete components of the health record that require provider completion to meet standards.

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

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.

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Practice Test

RHIT Record Content Management 2