HIM 101 FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026

HIM 101 FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026 HIMs most important functions - Answers storage and retrieval of patient information. Additional functions managed: Research and statistics, Cancer and/or trauma registries, and Birth certificate completion Critical support services managed by HIM - Answers Record processing, Monitoring of record completion, transcription, release of patient information, clinical coding, abstracting, and clinical data analysis HIM functions are: - Answers information centered and involves ensuring information quality, security, and availability. What dictates how the specific functions are carried out? - Answers The medium in which the information is stored. What is the goal of the health record system? - Answers To ensure that accurate information is available to authorized users to support quality patient care. What is record reconciliation? - Answers Hybrid System, upon patient discharge, receipt of the health record is checked with a discharge list for completeness. What are the most fundamental responsibilities of most HIM departments? - Answers storage and retrieval, record processing, record completion, transcription, release of information (ROI), and clinical coding What is the most important index used by the HIM department? What is it? What is its function? - Answers Master Patient Index (MPI) and is the permanent record of every patient ever seen in the healthcare entity. The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number. It is the initial point of documentation of the health record What is an Enterprise Master Patient index (EMPI)? - Answers references all patients in two or more facilities (ie integrated healthcare delivery system or health information exchange (HIE). What can function as a MPI? - Answers Often the patient registration system aka registration, admission, discharge, and transfer system (R-ADT) functions as the MPI What are the benefits of an electronic system? - Answers ability to access data by more than one individual at a time, edit checks can be applied against specific fields in the database to better ensure data accuracy, can be easily cross-referenced (when a patient has used more than one name during hospital or clinic visits), permits the use of several search techniques for locating an existing patient's information. When searching for a patient's record, what data elements can be used? - Answers medical record or billing number, date of birth, or social security number. Maintenance - To ensure the integrity of the MPI, several quality control mechanisms are essential and include: - Answers Quality - MPI prone to errors: misspellings, incorrect demographic data, transposition of numbers, and typographical errors are a few. Can cause treatment errors, billing problems and distorting data analysis of the organization's patient population. Duplicate, Overlay, and Overlap Medical Record Number Issues - Patient info not found upon admission and new record created; Or patient matched with wrong health record What is overlay? - Answers A patient is assigned another patient's medical record number comingling the medical information of both patient's resulting in problems in identifying what medical information belongs to which patient What is overlap? - Answers When more than one medical record number exists for the same patient within an enterprise at different facilities or in different databases. Often occur in organization with multiple facilities or can occur in the health information exchanges. Frequently problem arises when there are facility or organization mergers and an enterprise master person/patient index (EMPI) is created Strategies for MPI Integrity - Answers Integrity must be maintained in order to avoid patient safety, customer service, risk management, legal and other issues. MPI cleanup process - uses matching algorithms to identify and fix these problems. 3 types: are often part of the MPI application: a DETERMINISTIC algorithm requires an exact match of combined data elements such as name, birth date, sex, and social security number. PROBABILISTIC algorithm is base on complex mathematical formulas that analyze facility specific MPI data to determine precisely matched weight probabilities for attribute values of various data elements. RULES-BASED algorithm assigns weights, for significant values, to particular data elements and later uses these weights in the comparison of one record to another. The management of high-quality, error free MPI requires constant maintenance that includes: What is first line of defense? - Answers oversight, evaluation, and correction of errors. Prevention of problems should be the front line of defense. Communication back to the department responsible for the errors is key to providing awareness of the importance of the MPI and identifying opportunities for training and workflow issues. HIE - Answers Health Information Exchange= the sharing of health information electronically among two or more entities and also an organization that provides services to accomplish this information exchange. What is the purpose of an HIE organization? - Answers to increase the availability of health information to authorized stakeholders in order to improve quality and safety of healthcare delivery across the continuum. How do they ensure the integrity of patient identity in health information exchange - Answers Standardization of health information exchange practices is paramount. Paper based identification systems patient ID: Serial numbering System - Answers Patient receives a unique numerical identifier for each encounter or admission to a healthcare facility. Disadvantage: information about the patient's care and treatment is filed in separate health records and at separate locations. retrieval more difficult. inefficient. Unit numbering system - Answers most commonly used in large facilities. Patient receives a unique number on his first admission and the same number is used for subsequent encounters. Method most commonly used as the unique identifier in the EHR environment. Serial Unit Numbering System - Answers numbers are assigned in a serial manner, just as they are in the serial numbering system. However, during each new patient encounter, the previous health records are brought forward and filed under the last assigned health record number. Where should the process for checking patient records be located? - Answers in the facility's charting policies and procedures The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the: - Answers Unit numbering system The primary guide to locating a record in a numerical filing system is the - Answers Master Patient Index MPI What type of algorithm(s) may be used to identify duplicate medical record numbers? - Answers Deterministic, Probabilistic, and Rules Based. The health record number is typically assigned by: - Answers Patient registration Which of the following is used to locate an electronic health record - Answers Health record number John Smith, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is: - Answers Duplicates Which of the following should be part of a comprehensive MPI maintenance program? - Answers Advanced Person Search Which of the following is true about the Social Security Number? - Answers Both AHIMA and the Social Security Administration oppose using the Social Security number as the health record identifier Describe the electronic sharing of Information among two or more entities. - Answers Health Information Exchange Which identification system is at a disadvantage when there are two patients with the same name? - Answers Alphabetic HIM is rapidly changing due to? - Answers provisions mandated by the American Recovery and Reinvestment Act (ARRA) for the implementation of the electronic health record by 2014 Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-55. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system. - Answers Terminal digit filing The master patient index (MPI) is necessary to locate health records within the paper-based storage system for all the types of filing systems, except: - Answers Alphabetical The term used to describe a combination of paper-based and electronic health records is: - Answers Hybrid Which of the following is an advantage of a centralized unit filing system? - Answers One location in which to look for records Which filing system is considered to be the most efficient? - Answers Terminal-digit Purged records - Answers old records are removed from the file area. These records are often microfilmed, sent to off-site storage facilities or scanned. What are the benefits of document imaging? - Answers One of the greatest benefits of document imaging is increased efficiency by eliminating the requirement to move and track paper documents through workflow. Also helps solve the problem of lost or misplaced paper or microfiche documents. It saves money by reducing the need for storage space and by decreasing the work of file clerks. What type of paper-based storage conserves floor space by eliminating all but one or two aisles? - Answers Mobile filing units What feature of the filing folder helps locate misfiles within the paper-based filing system? - Answers Color coding In a paper-based system, the HIM department routinely delivers health records to: - Answers Nursing units Which of the following paper weights would be the most durable for the medical record folder? - Answers 20 What microfilm format is inefficient when patients have multiple admissions on microfilm? - Answers Roll What is the most common type of tracking system used to track paper-based health records? - Answers Outguide - usually made of strong colored vinyl with two plastic pockets. It is the size of a regular record folder and is placed in the record location when the record is removed from the file. What is compliance documentation? - Answers Compliance documentation includes all records necessary to protect the integrity of the compliance process and confirm the effectiveness of the program, including employee training documentation, reports from hotlines, results of internal investigations, results of auditing and monitoring, modifications to the compliance program, and self-disclosures. The documentation should be retained according to applicable federal and state law and regulations and must be maintained for a sufficient length of time to ensure its availability to prove compliance with laws and regulations The organizations legal counsel should be consulted regarding the retention of compliance documentation. AHIMA's recommended retention standards - Answers Permanently: Master Patient Index (MPI), Register of Births, Register of Deaths, and Register of surgical procedures 10 Years: Disease Index, Operative Index, and Physician index 10 Years after the age of majority: Fetal heart monitor records 10 Years after the most recent encounter: Patient health/medical records (adults) 5 Years: Diagnostic images (such as x-ray film) (adults) 5 Years after the age of majority: Diagnostic images (such as x-ray film) (Minors) Age of majority plus statue of limitations: Patient health/medical records (Minors) AHIMA's recommended destruction standards: - Answers Destroy the records so there is no possibility of reconstruction of information. Paper - burning, shredding, pulping and pulverizing. Microfilm or microfiche- recycling and pulverizing. Laser disks- pulverizing electronic Data- magnetic degaussing leaving the domains in random patterns with no preference to orientation, rendering previous data unrecoverable. Total data destruction does not occur until the original data and all backup information have been destroyed. Magnetic tapes - degaussing Destruction documentation: - Answers Date of destruction Method of destruction Description of the disposed records Inclusive dates covered A statement that the records were destroyed in the normal course of business The signatures of the individuals supervising and witnessing the destruction Maintenance of destruction documentation - Answers permanently - These are called certificates of destruction. Destruction services for destruction of records - Answers MUST meet HIPPA Privacy Rule and in addition: Indemnify the healthcare facility from loss due to unauthorized disclosure Require that the business associate maintain liability insurance in specified amounts, at all times the contract is in effect. Provide proof of destruction Specify the method of destruction Specify the time that will elapse between acquisition and destruction of data The method of destruction should be reassessed annually, based on current technology, accepted practices, and availability of timely and cost-effective destruction services. Under the False Claims Act, claims may be brought up to how many years? - Answers No more than 7 years Record retention should be based on: - Answers State regulations and AHIMA recommendations Which of the following is the appropriate method for destroying microfilm? - Answers Pulverizing The tool used to track paper-based health records is - Answers Outguide What facilitates efficiency, accuracy, and completeness of the health record? - Answers Record Processing The process of assuring that all records of discharged patients have been received by the HIM department for processing is called: - Answers record reconciliation Paper record assembly - Answers organized or assembled after the patient is discharged from the hospital or other setting - each page in the patient record is organized in a pre-established order review and analyze to acertain that there are no missing reports, forms, or required signatures and that all documents contain the patient's name and health record number - review for deficiencies called: - Answers quantitative analysis or record content review concurrent review - Answers personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record - review occurs concurrently with the patient's stay in the hospital. retrospective review - Answers quantitative analysis is completed the day following the patient's discharge from the hospital. deficiency slip - Answers indicates what reports are missing or require authentication and enters this information into a computer system that logs and tracks health record deficiencies or maintains a copy of the deficiency slip in a tickler file. A record with deficiencies is called AN INCOMPLETE RECORD. What is a Loose report? - Answers HIM departments often receive reports belonging to a health record that has already been assembled or scanned. These unprocessed reports are called loose reports or loose filing. Paper based corrections - Answers draw a single line through the original entry, writing error above the entry and then the practitioner signs, dates, and times the correction. addendum - Answers additional health information within the health record: Document the current date and time Write addendum and state the reason for the addendum, referring back to the original entry. Identify any sources of information used to support the addendum When writing an addendum, complete it as soon after the original note as possible. amendments - Answers clarification made to the health information after the original documentation has been final signed by the provider. Date, time, signed and attach to the original document that it is amending. Process that determines who is authorized to access patient information in the health record. - Answers Access control: involves determining which individuals or groups should be granted access, what portions of the health record should be available and what right should be granted. Access cards are often used in combination with passwords or personal identification numbers (PINS) as a method of authenticating identity fixed rules that must be followed for every form - Answers standards general direction about the design of the form - Answers guideline What should be done when the HIM department's error or accuracy rate is deemed unacceptable? - Answers A corrective action should be taken The forms design committee: - Answers Provides oversight for the development, review, and control of forms and computer screens Statements that define the performance expectations and/or structures or processes that must be in place are: - Answers Standards In a paper-based system, individual health records are organized in a pre-established order. This process is called - Answers Assembly Reviewing a health record for missing signatures and missing medical reports is called - Answers Analysis Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review? - Answers Retrospective Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies are called: - Answers delinquent records True or false In a paper-based record, errors should be completely obliterated - Answers False True or false Addendums should document the date the event actually happened - not the date it was documented - Answers True True or false The best practices for forms design is to use white paper with black ink - Answers True combination of paper-based and electronically stored healthcare records - Answers hybrid record - it is a transitional health record that at some point becomes an electronic health record. Electronic Document Management System - Answers technologies used to provide portions of an electronic health record and does more than manage documents after they are scanned..In a hybrid record environment, the document imaging component is often used to make paper-based records electronically accessible post-discharge. retraction - Answers involves removing a document from standard view, removing it from one record, and posting it to another within the electronic document management system. An annotation should be viewable to the clinical staff so that the retracted document can be consulted if needed. Resequencing - Answers involves moving a document from one place to another within the same episode of care. No annotation is needed. reassignment (synonymous with misfiles) - Answers involves moving the document from one episode of care to a different episode of care within the same patient record. An annotation should be viewable to the clinical staff so that the reassigned document can be considered if needed goal of hybrid record system - Answers to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes. Measures that limit an EHR user's ability to deny (repudiate) the origination receipt or authorization of a data exchange by that user - Answers Nonrepudiation - means to accept ie. electronic signatures Dual work processes - Answers refer to coexisting paper and electronic processes used in the hybrid health record evironment Which of the following chart-processing activities is eliminated with an EDMS that uses scanned images of barcoded forms? Chart preparation, Scanning, Assembly, Quality review - Answers Assembly One of the advantages of an EDMS is that it can: - Answers Help manage work tasks Which term indicates that a document has been removed from standard view? - Answers retraction Which term is the process of checking individual data elements, reports, or files against each other to resolve discrepancies - Answers reconciliation Which of the following could be used to determine if someone has the right to view a health record? - Answers photo identification What controls which version of the document will be viewable within the health record? - Answers version control - example one unsigned and one signed - documents must be flagged when an earlier version of a document exists and the date and time of the availability of each version of the document must be clearly documented. Can free-text data be easily located, retrieved, and manipulated by a search engine? - Answers Free-text data is undefined, unlimited, and unstructured. It is more difficult for a search engine to find, retrieve, and manipulate its data than structured text. Where does free-text data exist in the health record? - Answers Dictated and transcribed medical reports are an example. Many advantages of manipulation of data that the EHR offers are lost when the health record is comprised of large amounts of unstructured data. What are some specific risks to documentation integrity when using copy functionality? - Answers -Inaccurate or outdated information that may adversely impact patient care, - Inability to identify the author or what they thought. - Inability to identify when the documentation was created. - Inability to accurately support or defend E/M codes for professional or technical billing notes. - Propagation of false information. - Internally inconsistent progress notes Work Flow of digital dictation - Answers 1 physician dictates a medical report and the transcriptionist transcribes the dictation into a structured medical report. 2. The transcribed reports are electronically transmitted to the EHR. The EDMS attaches an auto-signature deficiency and the transcribed report is then electronically routed to a physician work queue for signature. What is another method used to capture dictated reports in the EHR - Answers Voice recognition technology - computer software captures the dictation and converts the dictation to text. Back end voice recognition software or voice recognition at the point of transcription is most commonly used for routine transcription of reports. As the practice of medical transcription evolves and voice recognition software is utilized, emphasis is placed on medical language editing, data quality control, and text/document management. EHR reconciliation processes - Answers As with paper-based and hybrid records, electronic health records require that the HIM professional verify that there is an EHR present in the system for every discharged patient and verification of reports. Data mining - Answers process of analyzing data from different perspectives and summarizing it into useful information. Analytical tool for large amounts of data. It is the"process of extracting information from a database and then quantifying and filtering discrete, structured data" (AHIMA) Access Control for EHRs - Answers The center of Medicare and Medicaid Services EHR certification criteria requires access control of the EHR. It states: "Assign a unique name and/or number for identifying and tracking user identity and establish controls that permit only authorized users to access electronic health information" What is the foundation on which access control is based? - Answers includes: identification, authentication, and authorization. Basic building block is identification usually performed through the user name and authorization Second element of access control - Answers authentication - the act of verifying a claim of identity, CMS states "verify that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information" EHR Certification requirement by the CMS - Answers 1. access control 2. authentication 3. Authorization 3 types of information for authentication - Answers something you know, something you have, or something you are. most common is the use of user names and passwords. Also Biometrics and access cards Right or permission given to an individual to use a computer resource or to use specific applications and access specific data; is also a set of actions that gives permission to an individual to perform specific functions such as view, write, edit, delete, or execute tasks - Answers Authorization - authorization software referred to as access control matrix. NONREPUDIATION measures - Answers limit an EHR user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user" (ie signatures as example) Amendments and Corrections in EHRs - Answers policies must be in place to assure the integrity of the information contained in the health record as a business record, as a legal health record, and as a patient care communication tool. The facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record. Functionality of EHR - Answers varies depending on the system used. refers to features in the EHR that allow the user to maintain different versions of a document, track changes made to a document, lock a document from changes, and create user profiles that limit who may edit entries and so forth. The ability to unlock a record should be given to only a few individuals and typically this would be the health information manager. The HIM professional must track changes to the health record and assure appropriate follow-up in any source systems or other data repositories. source systems - Answers refer to other computer systems that feed information into the EHR, which would also need to be corrected according to policy when corrections are made in the EHR. examples of policies regarding amending, correcting, or deleting health record entries - Answers - After a document or entry in a health record has a final signature on it, the only way to correct it is to add an addendum to the record. The addendum must have a separate signature, date, and time from the original entry. -The original version of the document in a corrected health record must be maintained. The version should be clearly indicated on the document. EX: reports should indicate, "Final Copy", "Preliminary Copy", or "final copy with corrections." -A health record should be locked from editing once the final signature has been applied. - The appearance of information added to the record to amend or correct it should be different than the original entry (that is, it may be a different color, italic, or bolded). Retention of EHR - Answers The facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs. There must also be a policy for the destruction of computer equipment and computer storage media when it is no longer functioning or has become obsolete. Data quality of EHR - Answers begins at the point of creation. Managing data input through good design of end-user interfaces increases the probability of quality data. Capture of EHR data: - Answers -Data are entered directly into the computer at the point of care - Paper documents are scanned and imaged -Other computer systems are interfaced with the EHR (laboratory, radiology) -Transcribed reports are electronically transmitted to the EHR According to AHIMA, what can provide for quality discrete, structured data that are more easily manipulated and analyzed? - Answers Input masks, lookup values, and validation rules Validation rules - Answers are applied to data fields to determine the validity of data entered into the EHR. Features include:drop-down menus, built-in data values, and check boxes. They do limit the practitioner to document complex cases Complex case entries - Answers may require the physician to use free text to adequately document a patient's condition. Free text is unstructured data and limits the facility's ability to report data. Errors - Answers another step to managing the quality data in EHR. Most generate error reports or utilize error queues when there are mismatches between the EHR and the other computer systems that feed information into the EHR. Must be a process in place to correct the errors. EHR selection features - Answers - Screen Design -Navigation Design - Input Design -Data validation -Output Design Features of Screen design: - Answers Should be evaluated for features that will contribute to the capturing of quality health data and will provide ease of use, which in turn help to provide quality data. -Clear navigational buttons - direct the user to the next step in the documentation process and buttons to view the previous screen are imperative to assuring the user can use the system with ease. - Clear labeling of buttons and data fields - Limiting the use of abbreviations on buttons and data fields - Consistent location on the screen of navigation buttons - Built-in alerts to notify the user of possible errors - Availability of references at the appropriate data field - Prompt for more information where appropriate -checks for warning signs or errors Features of Navigation design: - Answers - All controls should be clear and placed in an intuitive location on the screen - Use neutral colors and limit highlighting, flashing, and so forth to reduce eye fatigue - Limit choices and label commands -Provide undo buttons to make mistakes easy to override - Use consistent grammar and terminology - Provide a confirmation message for any critical function (such as deleting a file) Features of Input design: - Answers - Simplify data collection - Sequence data input to follow workflow - Provide a title for each screen - Minimize keystrokes by using pop-up menus - Use text boxes to enter text - Use a number box to enter numbers