HAAD RHIA Exam (page: 19)
HAAD Registered Health Information Administrator (RHIA)
Updated on: 15-Feb-2026

Viewing Page 19 of 367

In an acute care facility, the responsibility for education physicians and other health care providers regarding proper documentation policies belongs to the

  1. information security manager.
  2. clinical data specialist.
  3. health information manager.
  4. risk manager.

Answer(s): C



For inpatients, the first data item collected of a clinical nature is usually

  1. principal diagnosis.
  2. expected payer.
  3. admitting diagnosis.
  4. review of systems.

Answer(s): C



Documentation found in acute care health records should include core measure quality indications required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for pneumonia patients is

  1. beta blocker at discharge.
  2. blood culture before first antibiotic received.
  3. early administration of aspirin.
  4. discharged on antithrombotic.

Answer(s): B



One record documentation requirement shared by BOTH ascute care and emergency departments is

  1. patient's condition on discharge.
  2. time and means of arrival.
  3. advance directive.
  4. problem list.

Answer(s): A



In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

  1. standing orders.
  2. telephone orders.
  3. stop orders.
  4. discharge order.

Answer(s): D



Viewing Page 19 of 367



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