RHIA Exam Prep - Domain 1|31 Questions with Verified Answers,100% CORRECT

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RHIA Exam Prep - Domain 1|31 Questions with Verified Answers Problem-Oriented Health Record - CORRECT ANSWER A patient record in which clinical problems are defined and documented individually S... OAP - CORRECT ANSWER An acronym for a component of the problem-oriented medical record that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans. Case Management - CORRECT ANSWER 1. A process used by health professionals to manage a patient's healthcare; 2. the ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient. Minimum Data Set - CORRECT ANSWER Minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in a skilled nursing facility Outcomes and Assessment Information Set (OASIS) - CORRECT ANSWER A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs. Core Measure - CORRECT ANSWER Standardized performance measures developed to improve the safety and quality of healthcare Authentication - CORRECT ANSWER The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it Entity Relationship Diagram (ERD) - CORRECT ANSWER A specific type of data modeling used in conceptual data modeling and the logical-level modeling of relational databases Object - CORRECT ANSWER The basic component in an object-oriented database that includes both data and their relationships within a single structure. Relational Database - CORRECT ANSWER A type of database that stores data in predefined tables made up of rows and columns Unified Medical Language System (UMLS) - CORRECT ANSWER A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies Resident Assessment Protocols - CORRECT ANSWER In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items Case Mix Index - CORRECT ANSWER The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patients discharged Master Patient Index - CORRECT ANSWER A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death Health Record Matrix - CORRECT ANSWER Identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the health record Retention Schedule - CORRECT ANSWER A time line for various records retention based on factors such as federal and state laws, statutes of limitations, age of patient, competency of patient, accreditation standards, AHIMA recommendations, and operational needs Required Contents of a Patient's Record Prior to a Surgical Procedure - CORRECT ANSWER 1. A report of a complete history; and 2. Physical examination conducted no more than seven days prior to the surgery Aggregate Data - CORRECT ANSWER Data collected on large populations of individuals and stored in databases. This is used to develop information about groups of patients. Accession Data - CORRECT ANSWER Data Governance - CORRECT ANSWER Decision making and authority over data-related matters. Structured Data - CORRECT ANSWER Data that is organized and easy to retrieve and to interpret by traditional databases and data models. Principal Function of Health Records - CORRECT ANSWER Serve as the repository of clinical documentation relevant to the care of individual patients. Financial Data - CORRECT ANSWER Includes details about the patient's occupation, employer, and insurance coverage and is collected at the time of treatment. Authorship - CORRECT ANSWER The origin of recorded information that is attributed to a specific individual or entity. Ownership of the Health Record - CORRECT ANSWER Granted to the healthcare provider who generates the record - it is the business record of the healthcare provider. Chief Complaint - CORRECT ANSWER The reason a patient is seeking medical care Unstructured Clinical Information - CORRECT ANSWER Clinical documentation that is entered into the patient record as text (such as written notes, dictated reports, and legal forms) Primary Responsibility of a Coder - CORRECT ANSWER Ensure the accuracy of coded data Required Elements of an Emergency Care Record - CORRECT ANSWER 1. time and means of the patient's arrival; 2. treatment rendered; and 3. Instructions at discharge Entity-relationship Diagram (ERD) - CORRECT ANSWER The data model that is most widely used to illustrate a relational database structure. Clinical Data - CORRECT ANSWER All documentation entered in the medical record relating to the patient's diagnosis and treatment. [Show More]

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