RHIT - Registered Health Information Technician Health Record Content Management 2 — Questions and Answers
Question 1: What is the required timeframe for completing a history and physical (H&P) for inpatient admission per The Joint Commission?
- Within 48 hours
- Within 24 hours of admission (Correct answer)
- Within 72 hours
- Before discharge only
Correct answer: Within 24 hours of admission
The Joint Commission requires the H&P to be completed within 24 hours of inpatient admission.
If an H&P was performed within 30 days before admission, an update must be placed in the record within 24 hours noting any changes.
Question 2: Which document summarizes a patient's entire inpatient stay and must be completed at discharge?
- Admission assessment
- Discharge summary (Correct answer)
- Progress note
- Operative report
Correct answer: Discharge summary
The discharge summary provides a comprehensive overview of the entire hospital stay.
Required elements include reason for hospitalization, significant findings, procedures, treatment, condition at discharge, diagnoses, instructions, and follow-up plans.
Question 3: What is the purpose of an informed consent document?
- To record insurance information
- To document that the patient was informed of risks, benefits, alternatives and voluntarily agreed to treatment (Correct answer)
- To schedule follow-up appointments
- To record dietary preferences
Correct answer: To document that the patient was informed of risks, benefits, alternatives and voluntarily agreed to treatment
Informed consent documents that the patient received information about the proposed treatment and voluntarily agreed.
The consent process requires disclosure, comprehension, voluntariness, competence, and authorization. The conversation is the actual consent; the form documents it occurred.
Question 4: How soon after surgery must an operative report be documented?
- Within 48 hours
- Immediately after surgery with a brief note, and full report within 24 hours (Correct answer)
- Within one week
- At discharge only
Correct answer: Immediately after surgery with a brief note, and full report within 24 hours
A brief operative note must be written immediately; the full report must be available within 24 hours.
The brief note includes procedure performed, findings, specimens, estimated blood loss, and patient condition. The full report adds detailed technique description.
Question 5: What is the difference between authentication and authorship in health records?
- They are the same thing
- Authorship identifies who created the entry while authentication confirms it through a signature (Correct answer)
- Authentication creates the entry
- Neither applies to electronic records
Correct answer: Authorship identifies who created the entry while authentication confirms it through a signature
Authorship identifies who created the entry, while authentication is formally confirming and approving it.
CMS requires all entries be dated, timed, and authenticated. Electronic authentication must have unique credentials, timestamps, and non-repudiation features.
Question 6: What type of form documents the medications administered to a patient including dose, route, time, and administrator?
- Physician order sheet
- Medication Administration Record (MAR) (Correct answer)
- Nursing assessment form
- Discharge summary
Correct answer: Medication Administration Record (MAR)
The MAR documents each medication administered including name, dose, route, time, and administrator.
In electronic systems (eMAR), barcode medication administration (BCMA) verifies the five rights: right patient, medication, dose, route, and time.
RHIT - Registered Health Information Technician Health Record Content Management 2
What is the required timeframe for completing a history and physical (H&P) for inpatient admission per The Joint Commission?