RHIT - Registered Health Information Technician Data Integrity and Quality Questions and Answers — Questions and Answers
Question 1: A health information technician is performing a quality audit on the Emergency Department's patient records. They find several instances where the 'Time of Arrival' is recorded as later than the 'Time of Triage'. Which AHIMA data quality characteristic is being violated?
- Accuracy
- Consistency (Correct answer)
- Timeliness
- Comprehensiveness
Correct answer: Consistency
Consistency means that the data is reliable and the same across the entire patient encounter. In this scenario, the data is inconsistent because the time of arrival should logically precede the time of triage. While accuracy is related, consistency specifically addresses the logical coherence of data points within the record.
Question 2: A provider dictates a discharge summary and, upon review, realizes they stated the incorrect dosage for a medication. The electronic health record (EHR) system allows for amendments. What is the proper procedure for correcting this error?
- Delete the original dictated note and re-dictate the entire summary with the correct information.
- Create an addendum to the original note, clearly stating the correction, the reason for the change, and including the current date and time. (Correct answer)
- Overwrite the incorrect dosage in the original note with the correct information.
- Notify the IT department to have the original entry purged from the system.
Correct answer: Create an addendum to the original note, clearly stating the correction, the reason for the change, and including the current date and time.
The proper procedure for correcting an error in an EHR is to create a dated and signed addendum that clarifies the incorrect information. The original entry should not be deleted or overwritten to maintain the integrity of the legal health record and provide a clear audit trail.
Question 3: Which of the following is the PRIMARY goal of a data governance program in a healthcare organization?
- To increase the speed of data entry for clinical staff.
- To select and implement a new electronic health record system.
- To ensure data assets are managed securely and meet organizational quality and integrity standards throughout their lifecycle. (Correct answer)
- To reduce the number of required fields in patient registration forms.
Correct answer: To ensure data assets are managed securely and meet organizational quality and integrity standards throughout their lifecycle.
Data governance is the overall management of the availability, usability, integrity, and security of data used in an organization. Its primary goal is to establish a framework of policies and standards to ensure data is treated as a strategic asset, meeting quality and integrity requirements from creation to deletion.
Question 4: An RHIT is conducting a review of patient demographic data and finds multiple entries for the same patient with slight variations in the name (e.g., 'Jon Smith', 'John Smith', 'Jonathan Smith'). This issue directly impacts the integrity of the:
- Charge Description Master (CDM)
- Master Patient Index (MPI) (Correct answer)
- Medical Staff Bylaws
- Trauma Registry
Correct answer: Master Patient Index (MPI)
The Master Patient Index (MPI) is a database that maintains a unique identifier for each patient seen by a healthcare organization. Duplicate or overlaid records within the MPI compromise data integrity and can lead to significant patient safety and billing errors.
Question 5: A quantitative analysis of a health record focuses on:
- The presence or absence of required reports or signatures. (Correct answer)
- The medical necessity and justification for the services provided.
- The legibility and clarity of the physician's handwriting.
- The patient's satisfaction with the care they received.
Correct answer: The presence or absence of required reports or signatures.
Quantitative analysis, often called discharge analysis, is a review for the completeness and accuracy of the health record. It checks for the presence of all necessary components, such as required reports (e.g., history and physical, discharge summary) and necessary authentications or signatures. Qualitative analysis, by contrast, assesses the quality of the documentation itself.
Question 6: The principle of data integrity that ensures data is recorded at the time of the event or observation is known as:
- Legibility
- Accuracy
- Contemporaneousness (Correct answer)
- Attribution
Correct answer: Contemporaneousness
Contemporaneousness is a core principle of data integrity, often included in the ALCOA framework (Attributable, Legible, Contemporaneous, Original, Accurate). It means that data should be recorded at the time it was generated or observed, which supports data accuracy and reliability.
RHIT - Registered Health Information Technician Data Integrity and Quality Questions and Answers
A health information technician is performing a quality audit on the Emergency Department's patient records.
They find several instances where the 'Time of Arrival' is recorded as later than the 'Time of Triage'.
Which AHIMA data quality characteristic is being violated?