AHIMA RHIT (Registered Health Information Technician) — All Questions

A facility's master patient index (MPI) shows that one patient has been assigned two different medical record numbers within the same hospital. This error is best described as:

• a.An overlay
• b.An overlap
• c.A duplicate✓
• d.A merge

A duplicate exists when one patient is assigned two or more medical record numbers within the same facility, so the patient has two separate records. An overlay is the opposite and more dangerous error: two different patients share one medical record number, mixing their data. An overlap is one patient having different numbers across facilities in an enterprise MPI. A merge is the corrective action, not the error. MPI integrity is central to patient safety and data governance.

In the AHIMA data quality management model, the characteristic describing data that reflects the correct, true value is:

• a.Accuracy✓
• b.Completeness
• c.Timeliness
• d.Granularity

Accuracy means the data is correct and reflects the true value being captured. Completeness means all required data is present, timeliness means the data is recorded and available when needed, and granularity refers to the level of detail. These are distinct characteristics in the AHIMA data quality model, and the RHIT must be able to separate them because improvement efforts differ for each.

Under the Medicare Conditions of Participation and Joint Commission standards, a history and physical (H&P) for an inpatient must be documented:

• a.Within 24 hours of admission✓
• b.Within 48 hours of admission
• c.Within 72 hours of admission
• d.Within 7 days of admission

CMS Conditions of Participation and Joint Commission require the H&P to be completed and placed in the record within 24 hours of inpatient admission (and before surgery). An H&P completed within 30 days prior to admission may be used if an updated note confirms no changes. Monitoring H&P timeliness is a core HIM record-completion function.

In a problem-oriented medical record (POMR), progress notes are most commonly documented using which structured format?

• a.SOAP (Subjective, Objective, Assessment, Plan)✓
• b.SBAR (Situation, Background, Assessment, Recommendation)
• c.A source-oriented narrative grouped by department
• d.A flowsheet of vital signs only

The problem-oriented medical record uses SOAP notes — Subjective (patient statements), Objective (measurable findings), Assessment (diagnosis/impression), and Plan (treatment) — each tied to a numbered problem list. SBAR is a communication/hand-off tool, not a charting format. A source-oriented record organizes by department rather than by problem. Recognizing record formats is fundamental to record content and structure.

A nurse transcribes a verbal order given by a physician during an emergency. To properly authenticate that order, the ordering provider must:

• a.Date, time, and sign (countersign) the order within the timeframe set by CMS and facility policy✓
• b.Do nothing, because the nurse's signature makes it valid
• c.Write a new order at the patient's next admission
• d.Have the pharmacist co-sign it instead

Authentication of a verbal order requires the responsible provider to date, time, and sign it within the timeframe defined by CMS Conditions of Participation, state law, and facility policy. The nurse's transcription documents the order but does not authenticate it. Verbal orders should be limited to true necessity, and HIM monitors timely provider countersignature as part of documentation compliance.

A hospital is setting the retention period for the health record of a pediatric patient. The retention clock should generally run:

• a.Until the patient reaches the age of majority plus the applicable state statute of limitations✓
• b.Exactly five years from the date of the visit, then destroy
• c.Only until the patient is discharged
• d.For 30 days after the encounter

For minors, retention typically extends until the patient reaches the age of majority plus the state's statute of limitations, because the legal clock for a minor to bring an action does not begin until adulthood. Facilities follow the longest applicable requirement among state law, Medicare, and accreditation standards. A fixed short period would expose the facility to legal risk for records of minors.