Rhia Exam 1 Domain 1

Front 1

Transfer records

Back 1

A record created whever a patient is transfered from one facility to another.

Front 2

What does a transfer record contain?

Back 2

The summary of care while at the facility as well as the reason for transfer.

Front 3

Cheif complaint

Back 3

The nature and duration of the symptoms that caused the patient's illness and caused the patient to seek medical attention as stated in the patients own words.

Front 4

Data quality need to be __________

Back 4

Consistent

Front 5

When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a ___________.

Back 5

Health record matrix

Front 6

How should corrections to a record be entered properly?

Back 6

A single line through the error, add a note explaining the error, initial and date the error with the date that the error was discovered, and enter the correct info in chronological order.

Front 7

All documentation entered in the medical record relating to the patients diagnosis and treatment are considered this type of data _____.

Back 7

Clinical

Front 8

Data that have been grouped into meaningful categories according to a classification system are referred to as ___________ data.

Back 8

Coded

Front 9

Conducting an inventory of the facility's records, determine the format and location of the record storage, assigning each record a time period for preservation , and destroying records that are no longer needed are all components of:

Back 9

Retention program

Front 10

What is the principle function of health records?

Back 10

Serve as the repository of clinical documentation relevant to the care of individual patients.

Front 11

The insured party's member number identification number is and example of this type of data:

Back 11

Financial data

Front 12

Which part of the problem oriented medical record is used by many facilities that have adopted the whole problem oriented format?

Back 12

The SOAP form of progress notes.

Front 13

What materials are required elements in an emergency care record?

Back 13

Time and means of the patients arrival, treatment rendered, and instructions at discharge.

Front 14

What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records.

Back 14

Uniform data sets

Front 15

What is the unique identifier for their relation database patient table?

Back 15

Patient number

Front 16

What is used by a long term care facility to gather information about specific health status factors and include information about specific risk factors in the residents care?

Back 16

Minimum data set

Front 17

In a long term care setting, these are problem oriented frameworks for additional patient assessment based on problem identification items or triggered conditions

Back 17

Resident assessment protocols (RAPs)

Front 18

Documenting the full depth and breadth of data used in a healthcare an entity requires:

Back 18

Identifying the needs of data consumers

Front 19

What is an example of a M:M relationship: patient to hospital admissions or patients to consulting physicians or patients to hospital medical records or primary care physician to patients?

Back 19

Patient to consulting physician

Front 20

Mr Smith was admitted to University Hospital by Dr. Collins. Mr Smith's hospital bill will be paid by Blue Cross insurance. upon discharge from the hospital who owns the house record of Mr Smith?

Back 20

University Hospital

Front 21

Decision making and authority over data related matters is known as

Back 21

Data governance

Front 22

Abbreviations can be a source of patient safety issues due to the misinterpretation and miscommunication. Abbreviations in the health record:

Back 22

Should have only one meaning

Front 23

In icd-10-pcs what value is used if there is a character that does not apply to a given code?

Back 23

- (dash)

Front 24

The primary responsibility of a coder is to?

Back 24

Ensure quality of coded data

Front 25

Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this:

Back 25

Certificate of destruction

Front 26

What is the data model that is most widely used to illustrate a relational database structure?

Back 26

Entity relationship diagram ERD

Front 27

Anywhere hospital has mandated that the Social Security number will be displayed in the xxx - xx - xx xx format for their patients this is an example of the use of a:

Back 27

Mask

Front 28

Which of the following is a system in which the patient health record is kept in the same order as the nursing station and in the complete record?

Back 28

Universal

Front 29

Data that are collected on large populations of individuals and stored in databases are referred to as:

Back 29

Aggregate data

Front 30

The data elements in a patient's automated laboratory results are examples of:

Back 30

Structured data

Front 31

According to Joint Commission accreditation standards, which document must be placed in the patient's record before a surgical procedure may be performed?

Back 31

Report of history and physical examination

Front 32

Why could it be difficult for a health care entity to respond to pulling an entire, legal health record together for authorization request for information?

Back 32

It can exist in separate or multiple paper-based or electronic systems

Front 33

Data mapping is used to harmonize data sets or code sets. the code or data set from which the map originates is the:

Back 33

Source

Front 34

The process by which a person or entity who offered an EHR entry or document seeks to validate that they are responsible for the data contained within it is called

Back 34

Authentication

Front 35

Notes written by physicians or other practitioners as well as dictated and transcribed reports are examples of?

Back 35

Unstructured clinical information

Front 36

A significant challenge when handling hybrid records is complicated by the fact that:

Back 36

The requirements regulations and constrains of EHRs and paper records must be met.

Front 37

Bartering record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:

Back 37

Authorship integrity