RHIT Registered Health Information Technician 2 — Questions and Answers
Question 1: A health information technician discovers that two different medical record numbers have been assigned to the same patient. What is this error called?
- Overlay
- Duplicate (Correct answer)
- Overlap
- Merge error
Correct answer: Duplicate
When the same patient is assigned two or more medical record numbers, it is called a duplicate.
MPI integrity issues fall into two main categories: duplicates and overlays. A duplicate occurs when one patient has multiple MRNs, fragmenting their medical history across records.
Question 2: What is the primary function of the Uniform Hospital Discharge Data Set (UHDDS)?
- To standardize financial reporting
- To define a minimum set of data elements collected at discharge for inpatient stays (Correct answer)
- To establish coding guidelines for outpatient visits
- To track emergency department wait times
Correct answer: To define a minimum set of data elements collected at discharge for inpatient stays
The UHDDS defines the core minimum data elements that should be collected for every inpatient hospital discharge.
The UHDDS was developed in 1974 and defines minimum data elements including personal identification, dates, diagnoses, procedures, and disposition.
Question 3: Which of the following best describes the concept of data integrity in health information management?
- Data is stored in a fireproof safe
- Data is accurate, consistent, and reliable throughout its lifecycle (Correct answer)
- Data is always available electronically
- Data is backed up daily
Correct answer: Data is accurate, consistent, and reliable throughout its lifecycle
Data integrity refers to the accuracy, consistency, and reliability of data throughout its entire lifecycle.
Data integrity encompasses accuracy, completeness, consistency, timeliness, and validity. HIT professionals maintain data integrity through quality checks, audits, and access controls.
Question 4: What does the term 'legal health record' refer to in a healthcare organization?
- Only paper documents stored in the medical records department
- The official business record of patient care that the organization would produce in response to legal proceedings (Correct answer)
- A copy of the patient's record maintained by their attorney
- The patient's billing record
Correct answer: The official business record of patient care that the organization would produce in response to legal proceedings
The legal health record is the subset of all patient information that constitutes the organization's official business record.
The legal health record definition is organization-specific and determined by policy. It typically includes clinical documentation created by the organization's workforce.
Question 5: A RHIT is reviewing records and notices a physician documented 'CHF' without further specification. What action should the CDI specialist take?
- Code it as unspecified heart failure
- Query the physician for the type and acuity of heart failure (Correct answer)
- Assign the code for systolic heart failure
- Ignore the abbreviation
Correct answer: Query the physician for the type and acuity of heart failure
The CDI specialist should query the physician to obtain documentation of the specific type and acuity of heart failure.
ICD-10-CM provides highly specific codes for heart failure that distinguish between systolic, diastolic, combined, and other types, each with acuity modifiers.
Question 6: What is the purpose of a Notice of Privacy Practices (NPP) under HIPAA?
- To request payment from patients
- To inform patients about how their PHI may be used and their rights regarding their information (Correct answer)
- To document patient consent for surgery
- To report security breaches to the government
Correct answer: To inform patients about how their PHI may be used and their rights regarding their information
The Notice of Privacy Practices informs patients about how the covered entity may use and disclose their PHI and their rights.
HIPAA requires covered entities to provide patients with an NPP that describes uses and disclosures of PHI, patient rights, the entity's duties, and contact information.
RHIT Registered Health Information Technician 2
A health information technician discovers that two different medical record numbers have been assigned to the same patient.
What is this error called?