Free RHIT Exam Flashcards

AHIMA's RHIT blueprint covers data governance, privacy/security, analytics, revenue cycle, compliance, and leadership. Use the domain weights to decide study time, then adjust for your missed-question patterns.

Unscored questions placed on an exam to evaluate future use. RHIT candidates are not told which items are pretest, so answer every item as if it counts.

The organization-defined business record used for care, disclosure, and legal purposes. It is not every data element in every system; it is the official record set the organization can produce and defend.

Records used to make decisions about an individual, such as medical and billing records. HIPAA access and amendment rights focus on this set, not every internal note or quality file.

The policies, roles, standards, and controls that keep health data accurate, usable, secure, and accountable across its life cycle.

A person responsible for the meaning, quality, and appropriate use of a data set. Stewards help define data standards, resolve quality issues, and support consistent reporting.

The patient identity index that links each patient to the correct record across encounters. Strong MPI processes prevent duplicate records, overlays, and mismatched patient information.

A duplicate means one patient has more than one record. An overlay means information for two different patients is combined under one record, creating a higher patient-safety risk.

Preserve the original entry, mark the correction clearly, add the corrected information, and include date, time, and authentication. Never erase, obscure, or remove the original documentation.

The process of confirming who created or approved a record entry. Signatures, electronic signatures, dates, and times support accountability and record integrity.

The review, approval, versioning, and retirement of forms and templates. It keeps documentation tools standardized, compliant, and aligned with clinical workflow.

The original source of patient information, such as the health record or registration record. Secondary databases, registries, and reports are derived from primary sources.

The ability of systems to exchange health data and use the data meaningfully. True interoperability requires both transport and shared understanding of data meaning.

A modern health data exchange standard built around resources and APIs. It supports structured exchange of data such as patients, observations, medications, and encounters.

A standard terminology commonly used for laboratory and clinical observations. It helps different systems identify the same test or measurement consistently.

A clinical terminology used to represent problems, findings, procedures, and other clinical concepts with high detail for EHR documentation and analytics.

A normalized drug terminology that supports consistent medication names and identifiers across prescribing, pharmacy, and exchange systems.

The federal rule that governs uses and disclosures of protected health information and gives patients rights over their health information.

The rule focused on protecting electronic PHI through administrative, physical, and technical safeguards.

Use, request, or disclose only the PHI needed for the intended purpose. A key exception is treatment, where providers may access what is needed to care for the patient.

Core healthcare activities for which HIPAA generally permits PHI use and disclosure without a patient authorization.

A patient permission document for uses or disclosures not otherwise permitted by HIPAA. It should identify the information, recipient, purpose, expiration, signature, and revocation rights.

A patient's right to receive a list of certain PHI disclosures. Routine treatment, payment, operations, and disclosures made with authorization are generally excluded.

HIPAA gives individuals the right to inspect or obtain copies of PHI in the designated record set, with limited exceptions and required response timeframes.

A patient may request correction of PHI they believe is inaccurate or incomplete. The organization reviews the request and must follow the required approval or denial process.

When unsecured PHI is breached, covered entities must follow HIPAA notification rules for affected individuals, HHS, and sometimes media depending on size and circumstances.

A required contract when a vendor or partner creates, receives, maintains, or transmits PHI for a covered entity. It defines permitted uses and safeguard duties.

Security management actions such as risk analysis, workforce training, policies, contingency planning, and sanction procedures.

Technology controls for ePHI, such as unique user IDs, access controls, audit logs, encryption, integrity controls, and transmission security.

Protections for buildings, workstations, devices, and media that store or access ePHI. Examples include facility access controls and device disposal procedures.

The diagnosis classification system used in U.S. healthcare reporting. RHIT candidates should know conventions such as laterality, placeholders, extensions, and sequencing notes.

The inpatient procedure coding system used for hospital facility reporting. Its seven characters describe section, body system, root operation, body part, approach, device, and qualifier.

The procedure and service code set used heavily for physician and outpatient reporting. It includes evaluation and management, surgery, radiology, pathology, and medicine services.

Codes for supplies, drugs, equipment, and selected services not fully represented in CPT. Common examples include durable medical equipment and injectable drug codes.

The condition established after study to be chiefly responsible for the inpatient admission. It drives sequencing and can strongly affect MS-DRG assignment.

An indicator showing whether a diagnosis was present at the time inpatient admission began. POA data supports quality reporting, payment rules, and complication analysis.

A request for clarification when documentation is incomplete, conflicting, vague, or clinically unclear. It must be nonleading and supported by information already in the record.

A Medicare inpatient payment grouping based on principal diagnosis, procedures, complications or comorbidities, discharge status, age, sex, and other factors.

The average relative weight of a hospital's cases. A higher CMI suggests more resource-intensive patients, but it must be supported by accurate documentation and coding.

The facility's master list of billable items, services, supplies, and charges. Accurate maintenance supports clean claims, compliance, and revenue integrity.

The process of analyzing denied claims, correcting root causes, appealing when appropriate, and preventing repeat denials through documentation, coding, and workflow fixes.

Discharged Not Final Billed: accounts discharged but not yet ready for final billing. High DNFB can signal coding backlogs, missing documentation, or claim-edit problems.

A healthcare statistic calculated as total inpatient service days divided by the number of days in the period.

A utilization measure calculated as total discharge days divided by total discharges. It helps track resource use and care efficiency.

A bed-use measure: inpatient service days divided by bed count times days in the period, then multiplied by 100.

An organized database for a defined condition, procedure, population, or event. Registries support reporting, research, quality monitoring, and outcomes analysis.

The process of pulling defined data elements from source records into a registry, report, or database using standardized definitions.

A federal law addressing knowingly false or fraudulent claims submitted for government payment. HIM risk areas include unsupported coding, upcoding, and billing for services not documented.

Stark focuses on physician self-referrals for designated health services and is generally strict liability. Anti-Kickback targets remuneration intended to induce federal healthcare program referrals.

Plan, Do, Check, Act: a process-improvement cycle used to test changes, measure results, standardize what works, and repeat improvement.