RHIA Health Data Content and Structure 1 — Questions and Answers
Question 1: Which health record documentation standard requires that every entry be authenticated by the responsible provider?
- Joint Commission standard
- HL7 specification
- HIPAA Privacy Rule
- CMS Conditions of Participation (Correct answer)
Correct answer: CMS Conditions of Participation
CMS Conditions of Participation mandate that all health record entries be authenticated by the provider responsible for the care documented.
Question 2: What is the primary purpose of the master patient index (MPI) in a healthcare facility?
- Store clinical documentation
- Uniquely identify and track each patient across encounters (Correct answer)
- Assign diagnosis codes
- Manage insurance billing
Correct answer: Uniquely identify and track each patient across encounters
The MPI serves as the definitive source for uniquely identifying and tracking every patient across all visits and departments within a facility.
Question 3: Which data element in a health record is used to link all encounters for a single patient within a facility?
- Encounter number
- Medical record number (MRN) (Correct answer)
- Account number
- Social Security Number
Correct answer: Medical record number (MRN)
The medical record number (MRN) is the permanent identifier assigned to a patient that links all encounters within a facility.
Question 4: Which section of the acute care health record is legally required to be completed within 24 hours of admission?
- Discharge summary
- History and physical (H&P) (Correct answer)
- Operative report
- Consultation report
Correct answer: History and physical (H&P)
The history and physical must be completed within 24 hours of admission (or 30 days before) per Joint Commission standards.
Question 5: What does the term 'legal health record' define?
- Records subpoenaed by a court
- The subset of health information disclosed in response to legal requests (Correct answer)
- All records stored in the EHR system
- Records signed by an attorney
Correct answer: The subset of health information disclosed in response to legal requests
The legal health record is the organization-defined subset of health information that is disclosed in response to legal requests such as subpoenas.
Question 6: In health information management, what is the purpose of a deficiency analysis?
- Audit coding accuracy
- Identify incomplete or missing health record documentation (Correct answer)
- Review patient safety incidents
- Assess physician credentialing
Correct answer: Identify incomplete or missing health record documentation
Deficiency analysis identifies incomplete, missing, or unauthenticated entries in health records so they can be completed within required timeframes.
RHIA Health Data Content and Structure 1
Which health record documentation standard requires that every entry be authenticated by the responsible provider?