RHIT cheat sheet

Data governance defines decision rights, policies, and accountability for data assets; data stewardship assigns day-to-day responsibility for data quality.

Core data quality dimensions include accuracy, completeness, consistency, timeliness, validity, uniqueness, and accessibility.

The master patient index links patient identifiers across systems; duplicate record rate is a key identity-management metric.

A data dictionary documents each element's name, definition, format, allowed values, source, and owner.

The legal health record is the organization-designated subset of health information treated as the official business record.

UHDDS is the core inpatient discharge data set; OASIS is used for home health; HEDIS measures health plan performance.

Interoperability standards include HL7 v2 messaging, FHIR APIs, X12 administrative transactions, and DICOM imaging.

Retention schedules set minimum retention by record type and must reflect state law, statute of limitations, and payer contracts.

Record completion requires timely authentication and deficiency tracking; incomplete records are not filed as complete.

The HIPAA Privacy Rule permits use or disclosure for treatment, payment, and health care operations without patient authorization.

The minimum necessary standard applies to most non-treatment uses and disclosures; treatment disclosures are generally exempt.

Right of access: patients may obtain a copy of PHI generally within 30 days, with one 30-day extension and a reasonable cost-based fee.

Accounting of disclosures covers 6 years before the request and excludes treatment, payment, operations, and certain other disclosures.

Breach notification to affected individuals is required without unreasonable delay and no later than 60 days after discovery.

Security Rule safeguards are administrative, physical, and technical; encryption can support safe harbor for breached ePHI.

A valid authorization must describe the information, purpose, expiration, revocation rights, and be signed by the patient or representative.

Role-based access and audit trails enforce least privilege and support monitoring of PHI access.

Safe Harbor de-identification removes 18 specified identifiers; expert determination uses statistical methods to assess re-identification risk.

Descriptive analytics summarizes past performance; diagnostic explains causes; predictive forecasts outcomes; prescriptive recommends actions.

Mean is sensitive to outliers; median is the middle value in ordered data; mode is the most frequent value.

Rate = (number of events / population at risk) x multiplier, often 1,000 or 100,000.

Validity is measuring what is intended; reliability is consistency or repeatability of a measure.

Benchmarking compares performance with internal or external standards; risk adjustment improves fair comparison across populations.

Case mix index is the average DRG relative weight; higher CMI generally indicates more resource-intensive patients.

Statistical process control separates common-cause variation from special-cause variation using control limits.

HEDIS is a standardized set of health plan performance measures used for quality comparison and reporting.

Chart choice should match the question: trend over time uses a line chart; distribution uses a histogram.

Revenue cycle flow: scheduling/registration, charge capture, coding, claim submission, payment posting, denial management, collections.

Clean claim rate = clean claims / total claims submitted; higher rates reduce rework and days in accounts receivable.

Days in accounts receivable = (total accounts receivable / total charges) x days in period.

Gross revenue is total charges; net revenue is expected reimbursement after contractual adjustments.

The chargemaster contains charge codes, descriptions, and prices and must align with coding and billing rules.

Medicare inpatient DRG payment = MS-DRG relative weight x base rate, adjusted for wage index and other factors.

Denial root causes include registration errors, coding errors, missing authorization, and medical necessity.

Payer mix is the percentage of volume or revenue by payer and affects financial risk and collection strategy.

Point-of-service collections reduce patient bad debt and improve cash flow.

Compliance program elements include written policies, a compliance officer, training, auditing and monitoring, reporting, enforcement, and corrective action.

The Anti-Kickback Statute prohibits remuneration to induce referrals of items or services reimbursable by federal health care programs.

The Stark Law restricts physician referrals of designated health services when a financial relationship exists, unless an exception applies.

The False Claims Act imposes liability for knowingly submitting false claims and permits qui tam whistleblower actions.

HIPAA is enforced by OCR; penalties can include civil monetary penalties and corrective action plans.

The OIG Work Plan lists audit and enforcement priorities used for risk-based compliance auditing.

CMS Conditions of Participation set minimum health and safety standards for Medicare participation.

Sanction screening checks employees and vendors against the OIG LEIE and SAM exclusion lists.

Documentation and audit trails support medical necessity, coding accuracy, and compliance defensibility.

Leadership sets direction and vision; management coordinates resources and processes to achieve goals.

Span of control is the number of direct reports; wider spans require more delegation and standardized work.

Maslow's hierarchy: physiological, safety, social, esteem, and self-actualization needs; lower needs generally precede higher needs.

Herzberg separates hygiene factors that prevent dissatisfaction from motivators such as achievement and recognition.

Lewin's change model is unfreeze, change, and refreeze.

PDSA cycle is Plan, Do, Study, Act and supports iterative quality improvement.

SMART goals are specific, measurable, achievable, relevant, and time-bound.

FTE = total paid hours / standard full-time hours, commonly 2,080 hours per year.

SWOT analyzes strengths, weaknesses, opportunities, and threats for strategic planning.