RHIT - Registered Health Information Technician Health Record Content Management 2

Question 1

What is the required timeframe for completing a history and physical (H&P) for inpatient admission per The Joint Commission?

Accepted Answer

Within 24 hours of admission

Answer

The Joint Commission requires the H&P to be completed within 24 hours of inpatient admission.

Question 2

Which document summarizes a patient's entire inpatient stay and must be completed at discharge?

Accepted Answer

Discharge summary

Answer

The discharge summary provides a comprehensive overview of the entire hospital stay.

Question 3

What is the purpose of an informed consent document?

Accepted Answer

To document that the patient was informed of risks, benefits, alternatives and voluntarily agreed to treatment

Answer

Informed consent documents that the patient received information about the proposed treatment and voluntarily agreed.

Question 4

How soon after surgery must an operative report be documented?

Accepted Answer

Immediately after surgery with a brief note, and full report within 24 hours

Answer

A brief operative note must be written immediately; the full report must be available within 24 hours.

Question 5

What is the difference between authentication and authorship in health records?

Accepted Answer

Authorship identifies who created the entry while authentication confirms it through a signature

Answer

Authorship identifies who created the entry, while authentication is formally confirming and approving it.

RHIT - Registered Health Information Technician Practice Test