HIM Chapter 4 Exam Questions and
Answers
The overall goal of documentation standard is? - Answers -To ensure what is
documented in the health record is complete and accurately reflects the treatment
provided to the patient.
A hospital that participates in the Medicare and Medicaid programs must follow? -
Answers -The conditions of participation
When defining it's legal Health record, a healthcare provider organization must do which
of the following? - Answers -Assess the legal environment, System limitations, and HIE
agreements
Which of the following is the health record component that addresses the patient's
current complaints and symptoms and lists the patient's past medical, personal, and
family history? - Answers -Medical history
General documentation guidelines apply to? - Answers -All categories of health care
records
True or false? Only individuals authorized by the organizations policies should be
allowed to enter documentation in the health record - Answers -True
True or false? Healthcare entries should be documented at the time the services they
describe are rendered - Answers -True
True or false? auto authentication is the preferred method of authentication - Answers -
False
Which of the following creates a chronological report of the patient's condition and
response to treatment during the hospital stay? - Answers -Progress notes
What is the end result of the review process that shows the voluntary compliance with
guidelines of an external, nonprofit organization - Answers -
Which part of a medical history documents the nature and duration of the symptoms
that caused a patient to seek medical attention as stated in the patient's own words? -
Answers -Chief complaint
Answers
The overall goal of documentation standard is? - Answers -To ensure what is
documented in the health record is complete and accurately reflects the treatment
provided to the patient.
A hospital that participates in the Medicare and Medicaid programs must follow? -
Answers -The conditions of participation
When defining it's legal Health record, a healthcare provider organization must do which
of the following? - Answers -Assess the legal environment, System limitations, and HIE
agreements
Which of the following is the health record component that addresses the patient's
current complaints and symptoms and lists the patient's past medical, personal, and
family history? - Answers -Medical history
General documentation guidelines apply to? - Answers -All categories of health care
records
True or false? Only individuals authorized by the organizations policies should be
allowed to enter documentation in the health record - Answers -True
True or false? Healthcare entries should be documented at the time the services they
describe are rendered - Answers -True
True or false? auto authentication is the preferred method of authentication - Answers -
False
Which of the following creates a chronological report of the patient's condition and
response to treatment during the hospital stay? - Answers -Progress notes
What is the end result of the review process that shows the voluntary compliance with
guidelines of an external, nonprofit organization - Answers -
Which part of a medical history documents the nature and duration of the symptoms
that caused a patient to seek medical attention as stated in the patient's own words? -
Answers -Chief complaint
