HIM QUESTIONS 2024/25 QUESTIONS BANK WITH
CORRECTLY ANSWERED SOLUTIONS!!
What is not a core competency of HIM Professionals (Biomedical science,
technology, management, access and privacy, health information analysis) -
ANSWER Technology
Are non HIM members part of CHIMA board? - ANSWER Yes
CCHIM is responsible for (select all that apply: A. establishes the learning outcomes
for HIM programs, B identifies the standards of practice for entry level HIMs C.
Creates and manages the national certification exam) - ANSWER A, B and C
T or F: All entries in a health record whether paper or electronic need to be
authenticated? - ANSWER True
A newborn's record is filed with its mothers? - ANSWER No
T or F: Abbreviations are never allowed in a health record - ANSWER False
T or F: Specificity means that data needs to meet needs for clinical care only -
ANSWER False
T or F: Prior to elective surgery a patient will sign a Consent for Release of
Information - ANSWER False
What are some typical elements of qualitative record analysis - ANSWER
Diagnosis inconsistencies, inconsistencies in identification (name of patient, DOB),
time or location gaps, use of non approved abbreviations
What occurs after qualitative and quantitative record analysis is complete? -
ANSWER Coding and abstracting
What is the primary purpose of a health record? - ANSWER To support the
continuity of care
Secondary uses of the health record? - ANSWER Facilitate clinical decision
making, funding, education, research, operational management, legislation, support
quality of care
Qualitative analysis is an important tool to ensure data quality. It evaluates: potential
risk events, adverse drug reactions, quality of documentation, quality of care through
use of established criteria. - ANSWER Quality of documentation
T or F: While doing a final check on a paper record an HIM notices a lab report is
missing, once printed and added to the record, it can then be filed. - ANSWER
False- further analysis may be needed as well as coding and abstracting
,Discharge summary documentation must include: A. Detailed history of patient, B
discharge order, C. significant findings during hospitalization. D. A and C, E. All of
the above - ANSWER C. Significant findings during hospitalization
T or F: Redacting an entry in a record means deleting an error. - ANSWER False
T or F: If a patient presents their provincial health card at registration, there is no
need to search the MPI - ANSWER False
Where would you expect to find this entry in a record: The patient was admitted to
the medical unit. He was started on Levaquin 500mg and then later reduced to
250mg daily. The patient was hydrated with IV fluids. Cardiac enzymes were done 2
days. The chest pain resolved; ECG was unchanged. Patient will be followed as an
outpatient. - ANSWER Discharge summary
T or F: The chart order in a paper record is determined by a Health Record
Committee - ANSWER True
T or F: A delinquent record is the same as a deficient record. - ANSWER False
What is the key principle of the ADT? - ANSWER Collect once, use many
T or F: Verifying that a key document of a record is included and authenticated is a
key step in qualitative analysis? - ANSWER False. Quantitative analysis
T or F: The unintentional mis-identification of an individual is identity theft? -
ANSWER False
Someone registers at a desk and the clerk finds 2 entries in the MPI this is an
example of a: - ANSWER Duplicate
Accurate client identification requires: A Clearly defined data elements B.
Organizational policies and procedures that are audited and enforced C. Rigorous
staff training D. Standards for data recording E. All of the above - ANSWER E. All
of the above.
Advantages of concurrent coding include. A. Identifications of conditions that might
have been overlooked. B. More timely coding C. Faster qualitative and quantitative
analysis. D. All of the above - ANSWER D. All of the above.
What is the framework that facilitates communication between providers? -
ANSWER Nomenclature and terminologies
Who manages SNOMED-CT - ANSWER IHTSDO (International Health
Terminology Standards Development Organization)
Who manages ICD in Canada? - ANSWER CIHI
T or F: DSM-IV and CCI share codes - ANSWER False
,T or F: DSM-IV and ICD share codes - ANSWER True
What is the terminology of the EHR? - ANSWER SNOMED-CT
Coding is based on whose documentation? - ANSWER Physician's
Does the coder assign CMG or level of complexity? - ANSWER No
How many levels of complexity can there be in each CMG - ANSWER 4
Case Mix Groups (CMG) are used for what type of data? - ANSWER Inpatient
What are Major Clinical Categories related to? - ANSWER Case mix groups- each
major diagnosis has a major clinical category and then within that are the cmg
What are three primary uses of case mix groups? - ANSWER Utilization
management, planning and budgeting, funding
T or F: The RIW for a case can change from year to year? - ANSWER True
What is the relationship between RIW and ELOS? - ANSWER Greater the RIW,
greater the ELOS
Resource Utilization Group (RUG) are used with what type of cases? - ANSWER
Long term care
What are the 11 dimensions of data quality? - ANSWER CAT GRIP ACDC
Comprehensiveness, Accessibility, Timeliness, Granularity, Relevance, Integrity,
Precision, Accuracy, Consistency, Definition, Currency
How does Stats Canada define data quality? - ANSWER Fitness for use by clients
What can be used to assess data quality? - ANSWER A data quality framework?
Data quality processes should be involved in what stages of the information lifecycle
- ANSWER All
What is the best way to ensure data quality for electronic records? - ANSWER
Ensuring it at point of service
What is the best way to ensure data quality for paper records? - ANSWER
Retrospective audits
What is CRUD - ANSWER Create, Read, Update, Delete- access permissions
To whom should the results of a data quality evaluation be communicated to? -
ANSWER To those who use and collect the data
, Name 4 ways to ensure data quality? - ANSWER Built in edits and checks, up to
date data dictionary, training of staff and regular audits.
What is coded data used for within a hospital? - ANSWER Utilization management
and performance review
What is CIHI's reabstraction study? - ANSWER Expert coders will go to a hospital
and examine source documents and code them and then compare with original
abstracts. Often has a particular focus.
What is a database system? - ANSWER Components that will determine the
collection, management, storage and use of data in a database. Includes hardware,
software, people, processes and the data.
What is a database management system? - ANSWER An intermediary between the
user and the database. A collection of programs that manages the structure and
controls access to the data.
What is a data warehouse? - ANSWER A database that has at least 2 sources,
populated by years worth of data and allows for links to be made between different
sources of data.
Organizations must ensure their data is - ANSWER Protected, reconstructable,
tamper-proof and auditable.
What is the foundation of information? - ANSWER Quality daa
What is the foundation of data quality? - ANSWER Standards
What is the highest level of interoperability? - ANSWER Semantic
What are the 4 types of standards? - ANSWER Organization and people,
technology, information, and process.
Who is the Canadian representative with many international SDOs? - ANSWER
Infoway
What does HL7 facilitate? - ANSWER Communication between different medical
systems and different facilities. Sets language, structure, data-types, supporting
vocabs and terminologies.
What are the 3 options when you require a standard? - ANSWER Develop a new
one, adopt an existing one and adapt an existing one.
T or F: all provinces collect the exact same data for the DAD - ANSWER False
T or F: facilities can choose to track optional fields in the DAD - ANSWER True
How many sections are in the DAD - ANSWER 19 (though no 6 or 12)
CORRECTLY ANSWERED SOLUTIONS!!
What is not a core competency of HIM Professionals (Biomedical science,
technology, management, access and privacy, health information analysis) -
ANSWER Technology
Are non HIM members part of CHIMA board? - ANSWER Yes
CCHIM is responsible for (select all that apply: A. establishes the learning outcomes
for HIM programs, B identifies the standards of practice for entry level HIMs C.
Creates and manages the national certification exam) - ANSWER A, B and C
T or F: All entries in a health record whether paper or electronic need to be
authenticated? - ANSWER True
A newborn's record is filed with its mothers? - ANSWER No
T or F: Abbreviations are never allowed in a health record - ANSWER False
T or F: Specificity means that data needs to meet needs for clinical care only -
ANSWER False
T or F: Prior to elective surgery a patient will sign a Consent for Release of
Information - ANSWER False
What are some typical elements of qualitative record analysis - ANSWER
Diagnosis inconsistencies, inconsistencies in identification (name of patient, DOB),
time or location gaps, use of non approved abbreviations
What occurs after qualitative and quantitative record analysis is complete? -
ANSWER Coding and abstracting
What is the primary purpose of a health record? - ANSWER To support the
continuity of care
Secondary uses of the health record? - ANSWER Facilitate clinical decision
making, funding, education, research, operational management, legislation, support
quality of care
Qualitative analysis is an important tool to ensure data quality. It evaluates: potential
risk events, adverse drug reactions, quality of documentation, quality of care through
use of established criteria. - ANSWER Quality of documentation
T or F: While doing a final check on a paper record an HIM notices a lab report is
missing, once printed and added to the record, it can then be filed. - ANSWER
False- further analysis may be needed as well as coding and abstracting
,Discharge summary documentation must include: A. Detailed history of patient, B
discharge order, C. significant findings during hospitalization. D. A and C, E. All of
the above - ANSWER C. Significant findings during hospitalization
T or F: Redacting an entry in a record means deleting an error. - ANSWER False
T or F: If a patient presents their provincial health card at registration, there is no
need to search the MPI - ANSWER False
Where would you expect to find this entry in a record: The patient was admitted to
the medical unit. He was started on Levaquin 500mg and then later reduced to
250mg daily. The patient was hydrated with IV fluids. Cardiac enzymes were done 2
days. The chest pain resolved; ECG was unchanged. Patient will be followed as an
outpatient. - ANSWER Discharge summary
T or F: The chart order in a paper record is determined by a Health Record
Committee - ANSWER True
T or F: A delinquent record is the same as a deficient record. - ANSWER False
What is the key principle of the ADT? - ANSWER Collect once, use many
T or F: Verifying that a key document of a record is included and authenticated is a
key step in qualitative analysis? - ANSWER False. Quantitative analysis
T or F: The unintentional mis-identification of an individual is identity theft? -
ANSWER False
Someone registers at a desk and the clerk finds 2 entries in the MPI this is an
example of a: - ANSWER Duplicate
Accurate client identification requires: A Clearly defined data elements B.
Organizational policies and procedures that are audited and enforced C. Rigorous
staff training D. Standards for data recording E. All of the above - ANSWER E. All
of the above.
Advantages of concurrent coding include. A. Identifications of conditions that might
have been overlooked. B. More timely coding C. Faster qualitative and quantitative
analysis. D. All of the above - ANSWER D. All of the above.
What is the framework that facilitates communication between providers? -
ANSWER Nomenclature and terminologies
Who manages SNOMED-CT - ANSWER IHTSDO (International Health
Terminology Standards Development Organization)
Who manages ICD in Canada? - ANSWER CIHI
T or F: DSM-IV and CCI share codes - ANSWER False
,T or F: DSM-IV and ICD share codes - ANSWER True
What is the terminology of the EHR? - ANSWER SNOMED-CT
Coding is based on whose documentation? - ANSWER Physician's
Does the coder assign CMG or level of complexity? - ANSWER No
How many levels of complexity can there be in each CMG - ANSWER 4
Case Mix Groups (CMG) are used for what type of data? - ANSWER Inpatient
What are Major Clinical Categories related to? - ANSWER Case mix groups- each
major diagnosis has a major clinical category and then within that are the cmg
What are three primary uses of case mix groups? - ANSWER Utilization
management, planning and budgeting, funding
T or F: The RIW for a case can change from year to year? - ANSWER True
What is the relationship between RIW and ELOS? - ANSWER Greater the RIW,
greater the ELOS
Resource Utilization Group (RUG) are used with what type of cases? - ANSWER
Long term care
What are the 11 dimensions of data quality? - ANSWER CAT GRIP ACDC
Comprehensiveness, Accessibility, Timeliness, Granularity, Relevance, Integrity,
Precision, Accuracy, Consistency, Definition, Currency
How does Stats Canada define data quality? - ANSWER Fitness for use by clients
What can be used to assess data quality? - ANSWER A data quality framework?
Data quality processes should be involved in what stages of the information lifecycle
- ANSWER All
What is the best way to ensure data quality for electronic records? - ANSWER
Ensuring it at point of service
What is the best way to ensure data quality for paper records? - ANSWER
Retrospective audits
What is CRUD - ANSWER Create, Read, Update, Delete- access permissions
To whom should the results of a data quality evaluation be communicated to? -
ANSWER To those who use and collect the data
, Name 4 ways to ensure data quality? - ANSWER Built in edits and checks, up to
date data dictionary, training of staff and regular audits.
What is coded data used for within a hospital? - ANSWER Utilization management
and performance review
What is CIHI's reabstraction study? - ANSWER Expert coders will go to a hospital
and examine source documents and code them and then compare with original
abstracts. Often has a particular focus.
What is a database system? - ANSWER Components that will determine the
collection, management, storage and use of data in a database. Includes hardware,
software, people, processes and the data.
What is a database management system? - ANSWER An intermediary between the
user and the database. A collection of programs that manages the structure and
controls access to the data.
What is a data warehouse? - ANSWER A database that has at least 2 sources,
populated by years worth of data and allows for links to be made between different
sources of data.
Organizations must ensure their data is - ANSWER Protected, reconstructable,
tamper-proof and auditable.
What is the foundation of information? - ANSWER Quality daa
What is the foundation of data quality? - ANSWER Standards
What is the highest level of interoperability? - ANSWER Semantic
What are the 4 types of standards? - ANSWER Organization and people,
technology, information, and process.
Who is the Canadian representative with many international SDOs? - ANSWER
Infoway
What does HL7 facilitate? - ANSWER Communication between different medical
systems and different facilities. Sets language, structure, data-types, supporting
vocabs and terminologies.
What are the 3 options when you require a standard? - ANSWER Develop a new
one, adopt an existing one and adapt an existing one.
T or F: all provinces collect the exact same data for the DAD - ANSWER False
T or F: facilities can choose to track optional fields in the DAD - ANSWER True
How many sections are in the DAD - ANSWER 19 (though no 6 or 12)
