Discussion Videos Each Week You'll Be Introduced To ✓ Solved
Slide 1 Discussion Videos Each week you’ll be introduced to
Each week you’ll be introduced to a new RHIT Exam Domain. Domains are clusters of knowledge and tasks that are the basis of the RHIT Exam and represent a percentage of the exam. You can locate the domain listings in the Candidate’s Guide located on the AHIMA website. Participation in these presentations alone does not guarantee a passing score on the examination.
It is suggested that you follow the AHIMA Candidate Guide as a study guide preparing for your certification exam.
Domain 1: Data Content, Structure, and Information Governance encompasses 24-28% of the exam and includes applying health information guidelines, maintaining the integrity of the legal health record, educating clinicians on documentation, and coordinating document control.
The legal health record (LHR) includes documentation to support clinical treatment decisions, revenue reimbursement, and legal testimony related to the patient's condition and treatment. The definition of the LHR has evolved with the introduction of electronic medical records (EMRs), and each healthcare organization must define what their LHR includes.
Healthcare standards guide documentation processes, such as meaningfully using electronic health records (EHR), conforming to clinical documentation improvement (CDI), and ensuring compliance with legal and regulatory requirements. In addition, HIM professionals focus on the quality, security, and availability of health information.
Legal aspects of the LHR indicate that records from outside providers may or may not be included, and organizations need to consult legal advice to determine their policies. Forms design and document control are critical to maintain accurate health records, and committees can help oversee the development of forms.
Data dictionaries play a key role in health IT, listing all data elements and characteristics within a specific system. Secondary health information is derived from the primary health record and utilized for various purposes, including quality improvement, research, and administrative functions.
In summary, healthcare organizations must integrate guidelines, standards, and documentation processes effectively to maintain the integrity of health information governance and comply with regulatory requirements.
Paper For Above Instructions
The journey towards obtaining a Registered Health Information Technician (RHIT) certification is pivotal for aspiring health information professionals. This certification equips them with the necessary skills to navigate the complexities of health data management effectively. The RHIT Exam encompass various exam domains, each representing a different facet of health information management (HIM). This essay will delve into one of the critical domains covered, specifically focusing on data content, structure, and information governance, which comprises 24-28% of the overall exam.
Understanding the Domain
Data Content, Structure, and Information Governance create the backbone of a well-functioning health information management system. The primary goal of this domain is to ensure the application of health information guidelines and the maintenance of the legal health record's integrity. This involves applying standards such as the Joint Commission guidelines and Meaningful Use criteria, essential for ensuring compliance with state and federal regulations (Sayles, 2014).
The Legal Health Record
The legal health record (LHR) serves as a pivotal documentation tool that provides invaluable support for clinical decision-making, reimbursement processes, and legal interactions. The definition of LHR has evolved significantly, especially with the adoption of electronic health records (EHRs). Healthcare organizations must define what information their LHR contains, often consulting with legal counsel to determine compliance with state laws regarding the inclusion of external records (Association of American Medical Colleges [AAMC], 2020).
Importance of Documentation
Documentation integrity is not solely administrative but directly impacts the quality of patient care. It is crucial for HIM professionals to educate clinicians on proper documentation practices. This training ensures that documentation meets regulatory standards, enhances the quality of health records, and supports clinical documentation improvement (CDI) initiatives, which aim to enhance specificity in clinical documentation (Kanaan & Carr, 2009).
Governance of Health Information
Health information governance (HIG) is a structured framework that ensures the effective management of health data and information within an organization. The HIG framework encompasses data stewardship, which promotes accountability for data quality and security. Essential principles for effective data stewardship include protecting individual rights, implementing necessary security measures, and ensuring accountability (McKenzie, 2019).
Secondary Health Information
Secondary health information generated from primary health records supports various administrative, clinical, and research functions. Understanding the purpose and use of secondary health data is crucial as it aids in quality improvement initiatives, research projects, and regulatory reporting. For instance, registries can enhance population health management by tracking disease patterns and healthcare outcomes (National Institute of Health [NIH], 2021).
Conclusion
In conclusion, the complexities of health information management underscore the importance of effective training and governance within the realm of RHIT certification. As aspiring health information professionals prepare for their certification exams, a thorough understanding of the exam domains—particularly data content, structure, and information governance—will serve as a foundational element in their professional development. Committing to best practices in documentation and governance will greatly enhance the quality and integrity of health information systems moving forward.
References
- AAMC. (2020). Ensuring the integrity of the health record. Retrieved from www.aamc.org
- Kanaan, M., & Carr, L. (2009). Data Stewardship: A Guide to Data Governance in Higher Education. Retrieved from www.data-governance.com
- McKenzie, T. (2019). Governance in Health Care: A Roadmap for CIOs. Journal of Health Information Management, 33(1), 12-19.
- NIH. (2021). Secondary Data in Research. The National Institutes of Health. Retrieved from www.nih.gov
- Sayles, N. (2014). Health Information Management Technology: An Applied Approach. Cengage Learning.
- CMS. (2017). Conditions of Participation for Hospitals. Retrieved from www.cms.gov
- AHIMA. (2010). Principles of Health Information Governance. American Health Information Management Association. Retrieved from www.ahima.org
- American Health Information Management Association. (2018). AHIMA's Guidelines for Data Governance. Retrieved from www.ahima.org
- HealthIT.gov. (2020). Meaningful Use Guidelines. Retrieved from www.healthit.gov
- Joint Commission. (2020). National Patient Safety Goals. Retrieved from www.jointcommission.org