Question

please help! thats registered health info administrator (RHIA) exam preparation

Domain 1 Data Content, Structure, and Standards AH MITDAN 1. Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis her medical information was listed along with a summary of the care already provided. This information is documented on the a. Admitting physical evaluation record b. Patient's rights acknowledgment form c. Release of information form d. Transfer record 2. A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The X-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Abdominal pain b. Cholelithiasis c. Exploratory laparoscopy d. Ruptured appendix 3. Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith's health record? a. Data accuracy b. Data consistency c. Data accessibility d. Data comprehensiveness 4. Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data: a. Research b. Reference c. Coded d. Demographic 5. Which of the following is an acceptable means of authenticating a record entry? a. The physician's assistant signs for the physician. b. The HIM clerk stamps entries with the physician's signature stamp. c. The charge nurse signs the physician's name. d. The physician personally signs the entry. 6. All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data: a. Clinical b. Financial c. Identification d. Secondary 2 .

Answer 1

1. d. Transfer record (Since the medical information and summary of care was already provided)

2. a. Abdominal pain (Already mentioned in the question that the main complain of the patient was abdominal pain)

3. b. Data consistency (Since the data in the previous record and the data in the later record are not consistent)

4. c. Coded (One such example is ICD-10 codes which are categorized for different health and treatment scenarios)

5. d. The physician personally signs the entry (He is the one responsible for assigning such important aspect of data record)

6. a. Clinical (All documentation in the medical record related to patient's diagnosis and treatment are considered clinical data)