Health Data Content and Structure Flashcards
6 cards from real RHIA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Data Content and Structure flashcards as text
Which health record documentation standard requires that every entry be authenticated by the responsible provider?
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.
What is the primary purpose of the master patient index (MPI) in a healthcare facility?
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.
Which data element in a health record is used to link all encounters for a single patient within a facility?
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.
Which section of the acute care health record is legally required to be completed within 24 hours of admission?
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.
What does the term 'legal health record' define?
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.
In health information management, what is the purpose of a deficiency analysis?
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.