HIM has been recognized as an allied health profession since:

A. 1910
B. 1918
C. 1928
D. 2006

C

The hospital standardization movement was inaugurated by the:

A. American Health Information Management Association
B. American College of Surgeons
C. Record Librarians of North America
D. American College of Physicians

B

Throughout the years, HIM roles have;

A. Remained the same
B. Broadened in scope
C. Become more focused
D. Diminished

B

The traditional model of HIM practice was:

A. Department based
B. Information based
C. Electronically based
D. Analytically based

A

The new model of HIM practice is:

A. Information focused
B. Record focused
C. Department focused
D. Traditionally focused

A

What evolving role oversees the process that begins at the time of documentation through billing?

A. HIM director
B. Health record reviewer
C. Health data analyst
D. Revenue cycle management

D

The organization that accredits HIM programs is:

A. Joint Commission
B. CAHIIM
C. AHIMA
D. CCHIIM

B

What evolving role assesses quality health record banking?

A. Physician group consultant
B. Health record reviewer
C. Health data analyst
D. Terminology manager

B

The primary focus of AHIMA is to:

A. Ensure that health records are complete
B. Implement an electronic record in hospitals
C. Foster professional development of its members
D. Set and implement standards

C

Active members of AHIMA include those who:

A. Hold an AHIMA credential
B. Are graduate members
C. Are currently students in an accredited HIM program
D. Are senior members

D

Which of the following functions as the legislative body of AHIMA?

A. Board of Directors
B. House of Delegates
C. CCHIIM
D. CAHIM

B

Which of the following promotes education and research?

A. CCHIIM
B. CAHIIM
C. AHIMA
D. AHIMA Foundation

C

The virtual network used by AHIMA member is:

A. Certification
B. Fellowship
C. House of Delegates
D. Communities of Practice

D

We had 324 Medicare patients last month. This statement represents which of the following:

A. Information
B. Data
C. Content of the PHR
D. Patient-specific information

B

I am a patient. My medical history including information from myself and my physicians is stored on the internet. This is an example of which of the following:

A. Health record
B. EHR
C. PHR
D. Data

C

Which of the following is an example of primary purpose of the medical record?

A. Education
B. Policy making
C. Research
D. Patient care management

D

Examples of patient care delivery usage of the medical record include which of the following uses?

A. Developing of practice guidelines
B. Communication between caregivers
C. Reimursement for patient care
D. Getting patient involved in their own care

B

Critique this statement: The PHR and EHR are synonyms.

A. This is a true statement; both are controlled by the patient
B. This is a false statement as the PHR is controlled by the care providers and the EHR is controlled by the patient
C. This is a false statement as the PHR is controlled by the patient the EHR is controlled by the care provider
D. This is a true statement; both are controlled by the health care provider

C

TRUE OR FALSE-

The health record is the principal repository for data and information about the healthcare services provided to individual patients

True

TRUE OR FALSE-

The lab test "hemoglobin: 14.6 gm/ 110 ml" is considered information.

False

TRUE OR FALSE-

All the primary purpose of the health record are associated directly with the provision of patient care.

False

TRUE OR FALSE-

Submitting health record documentation to a third party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.

False

TRUE OR FALSE-

Use of the health record to study the effectiveness of a given drug is considered primary use of the health record.

False

Which of the following users of the health record is an example of an institutional user?

A. Third party payer
B. Accreditation organization
C. Physician
D. Employer

A

Which of the following users would utilize aggregate data?

A. Patient care providers
B. Coding and billing staff
C. Law enforcement officers
D. Patient care managers and support staff

D

I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?

A. Healthcare delivery
B. Medical review
C. Research
D. Education

C

Critique this statement: A user of health records includes only care providers who document in the health record or refer to it for patient care.

A. This is a true statement as defined by the IOM
B. This is a false statement as the information is used for other purposes such as analysis
C. This is a true statement as defined by the AHIMA
D. This is a false statement as the information contained in the health record is also used for patients to document in their own health record.

B

I work for CMS; how would I use the health record?

A. Make decisions on healthcare reimbursement
B. Medical Research
C. Issuing hospital and medical staff licenses
D. Accrediting healthcare organizations

A

TRUE OR FALSE-

A physical therapist is documenting in the health record is an institutional health record user.

False

TRUE OR FALSE-

An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.

False

TRUE OR FALSE-

CMS uses data to accredit hospitals

False

TRUE OR FALSE-

A researcher uses data to determine the recommended treatment.

True

TRUE OR FALSE-

Patients do not have the right to add missing information to the health record

False

A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical tool?

A. Clinical decision support
B. Electronic records
C. Results management
D. Order-entry/order management

A

I just told my physician something embarrassing about myself. I told him because I expect him to use the information for my care only. This concept is called:

A. Data relevancy
B. Security
C. Privacy
D. Confidentiality

D

Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic would be justification for not collecting this information?

A. Accuracy
B. Consistency
C. Granularity
D. Relevancy

D

It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic would be the justification for not doing this, but rather sharing information between the systems?

A. Accuracy
B. Consistency
C. Granularity
D. Relevancy

B

According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information.

A. Data application
B. Data collection
C. Data warehousing
D. Data analysis

D

A characteristic of data whose values are defined at the appropriate level of detail

A. Data granularity
B. Security
C. Privacy
D. Data comprehensive
E. Data relevancy

A

A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records

A. Data granularity
B. Security
C. Privacy
D. Data comprehensive
E. Data relevancy

B

A characteristic of data where the data are useful

A. Data granularity
B. Security
C. Privacy
D. Data comprehensive
E. Data relevancy

E

An individual's right to control access to his or her personal information

A. Data granularity
B. Security
C. Privacy
D. Data comprehensive
E. Data relevancy

C

A characteristics of data that includes every required data element

A. Data granularity
B. Security
C. Privacy
D. Data comprehensive
E. Data relevancy

D

Which two major types of data are contained in the health record?

A. Nursing and Physician
B. Administrative and clinical
C. Demographic and financial
D. Surgical and medical

B

Which of the following terms refers to state county regulations that healthcare facilities must meet to be permitted to provide care?

A. Accreditation
B. Bylaws
C. Certification
D. Licensure

D

Which of the following should not be found in a medical history?

A. Chief complaint
B. Vital signs
C. Present illness
D. Review systems

B

An attending physicians requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report?

A. Consultation
B. Progress note
C. Operative report
D. Discharge summary

A

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?

A. Flow record
B. Vital signs record
C. Care plan
D. Surgical note

C

Written or spoken permission to proceed with care is classified as:

A. Expressed consent
B. Acknowledgement
C. Advance directive
D. Implied consent

A

Which of the following reports provides information on tissue removing during surgery?

A. Operative report
B. Laboratory report
C. Pathology report
D. Anesthesia report

C

Sleeping patterns, head chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following record?

A. Obstetric
B. Newborn
C. Surgical
D.Emergency

B

Which of the following is not considered patient demographic information?

A. Patient's date of birth
B. Name of next kin
C. Type of admission
D. Admitting diagnosis

D

Which of the following administrative documents names the patient's choice of legal representative for healthcare purposes?

A. Advance Directive
B. Patient Bill of Rights
C. Notice of Privacy Practices
D. Authorization for Release of Information

A

1. Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?

A. Ambulatory care
B. Emergency care
C. Long-term care
D. Rehabilitation care

B

Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record?

A. Ambulatory care
B. Emergency care
C. Long-term care
D. Rehabilitation care

A

The ambulatory surgery record contains information most similar to:

A. Physician's office record
B. Emergency care records
C. Hospital operative record
D. Hospital obstetric records

C

Which standardization tool is used to assess Medicare-certified rehabilitation facilities?

A. Outcomes and Assessment Information Set (OASIS)
B. Resident assessment protocol (RAP)
C. Patient assessment instrument (PAI)
D. Minimum Data Set (MDS)

C

Interdisciplinary care plans are an important part of which type of health record?

A. Emergency department
B. Ambulance
C. Hospice care
D. Ambulatory care

C

Portions of a treatment record may be maintained in a patient's home in which two types of settings?

A. Hospice and behavioral health
B. Home health and end-stage renal disease
C. Obstetric and gynecologic care
D. Rehabilitation and correctional care

B

A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record?

A. Rehabilitation care
B. Ambulatory care
C. Behavioral health
D. Personal health

C

Paper records may require thinning in which two settings?

A. Home health and hospice
B. Rehabilitation and end-stage renal disease
C. Ambulatory care and behavioral health
D. Long-term care and correctional services

D

A growth and development record may be found in what type of record?

A. Rehabilitation care
B. Pediatric
C. Behavioral health
D. Obstetric

B

The document that indicates current and past medical condition is:

A. MDS
B. RAPs
C. Problem list
D. PAI

C

Which of the following is an accrediting organization?

A. State regulating services
B. American Health Information Management Association
C. DNV (De Norske Veritas)
D. Centers for Medicare and Medicaid Services

C

An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation under its guidelines do not need to:

A. Meet licensure standards
B. Undergo Medicare certification surveys
C. Undergo accreditation survey's
D. Meet Medicare certification standards

B

Which group focuses on accreditation of managed care and preferred provider organizations?

A. Accreditation Association for Ambulatory Healthcare
B. National Committee for Quality Assurance
C. Commission on Accreditation of Healthcare Organizations
D. Joint Commission on Accreditation of Healthcare Organization

B

Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patient record?

A. Facility rules and regulations
B. Accreditation standards
C. Licensure standards
D. Conditions of Participation

A

Which of the following groups has instituted a health record-prohibited abbreviation list?

A. National Committee for Quality Assurance
B. Joint Commission on Accreditation of Healthcare Organization
C. American Osteopathic Association
D. Centers of Medicare and Medicaid Service

B

Which type of health record includes both paper and computerized components?

A. Hybrid
B. Electronic
C. Problem-oriented
D. Source-oriented

A

Which of the following is a disadvantage of an EHR over a paper based record?

A. Allows customization to user needs
B. Permits multiple users at the same time
C. Enables duplicate copies to be made easily
D.Requires privacy and security measures

D

In an integrated health record, documentation by health professionals is organized:

A. In sections by type of professional
B. In sections by problem number
C. Intermixed in data sequence
D. Depends on facility policy

C

The patient indicates that her pain is worse, In which part of SOAP note would this information be recorded?

A. Subjective
B.Objective
C. Assessment
D. Plan

A

Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?

A. Database management
B. Image processing
C. Text processing
D. Vocabulary standards

B

Which of the following is true of paper-based records?

A. They are susceptible