AHIMA RHIA Course Notes

Govern the health record and its data across the lifecycle. Know documentation integrity, data quality, data dictionaries, enterprise standards, analytics, information governance, retention/destruction, and MPI/identity integrity. On the exam, choose traceable, standardized, validated processes over hidden edits, local improvisation, or unverified assumptions.

• Treating an untraceable overwrite as an acceptable correction.

• Traceability beats convenience.

Apply HIPAA and related privacy/security rules to access, use, disclosure, breach response, and request workflows. Know the designated record set, 30-day access clock, personal representatives, minimum-necessary exceptions, role-based access/audit controls, breach notification timelines, and the administrative/physical/technical Security Rule safeguard families.

• Memorizing a false 72-hour HHS HIPAA breach deadline.

• Classify the request before applying a HIPAA rule.

Turn health data into reliable information and make technology work safely. Focus on reporting and visualization, database relationships and SQL concepts, focused audits, workflow/RCA/PDSA, HIE/FHIR/USCDI and information blocking, interface integrity/provenance, the SDLC, and healthcare statistics. Validate definitions and denominators before interpreting results.

• Assuming a sudden dashboard improvement is real without validating the data pipeline.

• Identify the question type before choosing a chart or statistic.

Connect documentation and coding to compliant reimbursement. Distinguish IPPS, OPPS, and professional payment concepts; apply current ICD-10-CM/PCS guidelines; understand inpatient versus outpatient uncertain diagnoses; monitor documentation integrity and CDI; manage DNFB/A/R/denials; and use NCCI/edit/audit controls for revenue integrity.

• Calling OPPS an outpatient physician payment schedule.

• Setting first: inpatient, hospital outpatient, or professional.

Manage people, vendors, budgets, compliance, improvement, and projects. Favor structured, measurable management processes: strategy and change governance, vendor due diligence/BAAs/SLAs, competency-based HR, root-cause analysis and PDSA, outcome-based training, budget/variance reasoning, survey corrective action, OIG-style compliance infrastructure, and formal project change control.

• Choosing a vendor solely on lowest price.

• Use structured, documented, measurable processes.