RHIT Record Content Management 2 — Questions and Answers
Question 1: Which document in the health record serves as the primary source of diagnosis and procedure codes for billing?
- Nursing assessment
- Discharge summary (Correct answer)
- Operative report
- Consultation note
Correct answer: Discharge summary
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?
- Correct the nursing note to match the physician's note
- Query the attending physician to clarify the discrepancy (Correct answer)
- Use the physician's note since it supersedes nursing documentation
- Flag the record and delay coding until resolved
Correct answer: Query the attending physician to clarify the discrepancy
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)?
- Patient's date of birth linked to a diagnosis
- De-identified data with all 18 identifiers removed (Correct answer)
- Patient's geographic region smaller than a state
- Patient's medical record number
Correct answer: De-identified data with all 18 identifiers removed
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?
- To audit coding accuracy after discharge
- To identify incomplete records requiring physician completion (Correct answer)
- To review records for potential fraud
- To assess the quality of nursing documentation
Correct answer: To identify incomplete records requiring physician completion
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?
- Records must be retained for 7 years from date of service
- Records must be retained until the patient reaches the age of majority plus the standard retention period (Correct answer)
- Records are destroyed when the patient turns 18
- Minor records follow the same 10-year retention as adult records
Correct answer: Records must be retained until the patient reaches the age of majority plus the standard retention period
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.
Question 6: An electronic health record system automatically timestamps all entries. What is the primary benefit of this feature for record integrity?
- It speeds up the coding process
- It establishes a verifiable audit trail for documentation (Correct answer)
- It eliminates the need for physician signatures
- It reduces storage costs for the facility
Correct answer: It establishes a verifiable audit trail for documentation
Automatic timestamps create an audit trail that verifies when documentation was created or modified, supporting record integrity.
Question 7: Which of the following best describes a hybrid health record?
- A record stored on two separate servers for redundancy
- A record that contains both paper and electronic components (Correct answer)
- A record accessible by both inpatient and outpatient providers
- A record that uses two different EHR vendor systems
Correct answer: A record that contains both paper and electronic components
A hybrid health record is one in which documentation exists in both paper and electronic formats during a transition to a fully electronic system.
RHIT Record Content Management 2
Which document in the health record serves as the primary source of diagnosis and procedure codes for billing?