CHIM NCE EXAM COMPLETE QUESTIONS AND 100%
VERIFIED ANSWERS (PASS GUARANTEE)
1. Q: What is the primary purpose of the health record? ANSWER To
document patient care and serve as a communication tool among healthcare
providers.
2. Q: Which law mandates privacy and security standards for health
information? ANSWER The Health Insurance Portability and Accountability
Act (HIPAA) of 1996.
3. Q: What does PHI stand for? ANSWER Protected Health Information.
4. Q: How long must adult health records typically be retained? ANSWER
Generally 7-10 years after the last patient encounter, but varies by state law.
5. Q: What is the minimum retention period for minor health records?
ANSWER Until the age of majority plus the statute of limitations (typically age
18-21 plus 7-10 years).
6. Q: What is a master patient index (MPI)? ANSWER A database that
maintains unique patient identifiers and demographic information for all
patients treated at a healthcare facility.
7. Q: What is the purpose of data quality management? ANSWER To
ensure health data is accurate, complete, consistent, timely, and valid.
8. Q: What does EHR stand for? ANSWER Electronic Health Record.
9. Q: What is the difference between an EHR and EMR? ANSWER An
EHR is designed to be shared across multiple healthcare settings, while an EMR
is typically limited to one practice or organization.
10. Q: What is a hybrid health record? ANSWER A health record that
contains both paper and electronic components.
11. Q: What is data integrity? ANSWER The accuracy, consistency, and
reliability of data throughout its lifecycle.
,12. Q: What is the primary function of a health information exchange
(HIE)? ANSWER To facilitate the electronic sharing of health information
across organizations.
13. Q: What is quantitative analysis of health records? ANSWER Review
of health records for completeness and required elements.
14. Q: What is qualitative analysis of health records? ANSWER Review of
health records for documentation quality and clinical accuracy.
15. Q: What is a delinquent health record? ANSWER A record that has not
been completed within the specified time frame (typically 30 days after
discharge).
16. Q: What is the purpose of a deficiency system? ANSWER To track
incomplete health records and notify providers of missing documentation.
17. Q: What is an amendment to a health record? ANSWER A correction
or addition made to a health record while maintaining the original entry.
18. Q: What is the legal health record? ANSWER The documentation that
would be released in response to a legal request for health records.
19. Q: What is metadata? ANSWER Data that describes other data, such as
when a document was created, by whom, and when it was modified.
20. Q: What is the purpose of record reconciliation? ANSWER To ensure
all records leaving a unit or department are accounted for and properly filed.
21. Q: What is a discharge summary? ANSWER A comprehensive report
that summarizes a patient's hospitalization, including reason for admission,
significant findings, procedures performed, treatment provided, condition at
discharge, and follow-up plans.
22. Q: What is the purpose of an operative report? ANSWER To document
the details of a surgical procedure, including pre- and post-operative diagnoses,
procedure performed, findings, and complications.
23. Q: What is an advance directive? ANSWER A legal document
expressing a patient's wishes regarding medical treatment if they become unable
to make decisions.
24. Q: What is informed consent? ANSWER Permission granted by a patient
for a medical procedure after being informed of risks, benefits, and alternatives.
25. Q: What is the purpose of authentication in health records? ANSWER
To verify the identity of the person creating or modifying a health record entry.
, 26. Q: What is auto-authentication? ANSWER A prohibited practice where
documentation is automatically signed without physician review.
27. Q: What is a verbal order? ANSWER An order given orally by a
physician and transcribed by authorized personnel.
28. Q: What does SOAP stand for in documentation? ANSWER
Subjective, Objective, Assessment, Plan.
29. Q: What is the Joint Commission? ANSWER An independent, not-for-
profit organization that accredits and certifies healthcare organizations.
30. Q: What is meaningful use? ANSWER A program that incentivizes
healthcare providers to use certified EHR technology to improve patient care.
31. Q: What is the purpose of a consent form? ANSWER To document
patient permission for treatment, release of information, or participation in
research.
32. Q: What is copy and paste in EHR documentation? ANSWER The
practice of duplicating previously documented information into a new entry,
which can lead to errors.
33. Q: What is chart tracking? ANSWER A system to monitor the location
and movement of health records.
34. Q: What is loose filing? ANSWER The process of adding documents to
health records after discharge.
35. Q: What is terminal digit filing? ANSWER A filing system that uses the
last digits of the medical record number to organize records.
36. Q: What is straight numerical filing? ANSWER A filing system where
records are arranged in ascending numerical order.
37. Q: What is alphabetic filing? ANSWER A filing system that organizes
records by patient last name.
38. Q: What is the primary advantage of terminal digit filing? ANSWER
Even distribution of records and workload across file areas.
39. Q: What is a file expansion rate? ANSWER The percentage increase in
the number of records over a specific period.
40. Q: What is record circulation? ANSWER The movement of health
records from storage to points of use and back.
VERIFIED ANSWERS (PASS GUARANTEE)
1. Q: What is the primary purpose of the health record? ANSWER To
document patient care and serve as a communication tool among healthcare
providers.
2. Q: Which law mandates privacy and security standards for health
information? ANSWER The Health Insurance Portability and Accountability
Act (HIPAA) of 1996.
3. Q: What does PHI stand for? ANSWER Protected Health Information.
4. Q: How long must adult health records typically be retained? ANSWER
Generally 7-10 years after the last patient encounter, but varies by state law.
5. Q: What is the minimum retention period for minor health records?
ANSWER Until the age of majority plus the statute of limitations (typically age
18-21 plus 7-10 years).
6. Q: What is a master patient index (MPI)? ANSWER A database that
maintains unique patient identifiers and demographic information for all
patients treated at a healthcare facility.
7. Q: What is the purpose of data quality management? ANSWER To
ensure health data is accurate, complete, consistent, timely, and valid.
8. Q: What does EHR stand for? ANSWER Electronic Health Record.
9. Q: What is the difference between an EHR and EMR? ANSWER An
EHR is designed to be shared across multiple healthcare settings, while an EMR
is typically limited to one practice or organization.
10. Q: What is a hybrid health record? ANSWER A health record that
contains both paper and electronic components.
11. Q: What is data integrity? ANSWER The accuracy, consistency, and
reliability of data throughout its lifecycle.
,12. Q: What is the primary function of a health information exchange
(HIE)? ANSWER To facilitate the electronic sharing of health information
across organizations.
13. Q: What is quantitative analysis of health records? ANSWER Review
of health records for completeness and required elements.
14. Q: What is qualitative analysis of health records? ANSWER Review of
health records for documentation quality and clinical accuracy.
15. Q: What is a delinquent health record? ANSWER A record that has not
been completed within the specified time frame (typically 30 days after
discharge).
16. Q: What is the purpose of a deficiency system? ANSWER To track
incomplete health records and notify providers of missing documentation.
17. Q: What is an amendment to a health record? ANSWER A correction
or addition made to a health record while maintaining the original entry.
18. Q: What is the legal health record? ANSWER The documentation that
would be released in response to a legal request for health records.
19. Q: What is metadata? ANSWER Data that describes other data, such as
when a document was created, by whom, and when it was modified.
20. Q: What is the purpose of record reconciliation? ANSWER To ensure
all records leaving a unit or department are accounted for and properly filed.
21. Q: What is a discharge summary? ANSWER A comprehensive report
that summarizes a patient's hospitalization, including reason for admission,
significant findings, procedures performed, treatment provided, condition at
discharge, and follow-up plans.
22. Q: What is the purpose of an operative report? ANSWER To document
the details of a surgical procedure, including pre- and post-operative diagnoses,
procedure performed, findings, and complications.
23. Q: What is an advance directive? ANSWER A legal document
expressing a patient's wishes regarding medical treatment if they become unable
to make decisions.
24. Q: What is informed consent? ANSWER Permission granted by a patient
for a medical procedure after being informed of risks, benefits, and alternatives.
25. Q: What is the purpose of authentication in health records? ANSWER
To verify the identity of the person creating or modifying a health record entry.
, 26. Q: What is auto-authentication? ANSWER A prohibited practice where
documentation is automatically signed without physician review.
27. Q: What is a verbal order? ANSWER An order given orally by a
physician and transcribed by authorized personnel.
28. Q: What does SOAP stand for in documentation? ANSWER
Subjective, Objective, Assessment, Plan.
29. Q: What is the Joint Commission? ANSWER An independent, not-for-
profit organization that accredits and certifies healthcare organizations.
30. Q: What is meaningful use? ANSWER A program that incentivizes
healthcare providers to use certified EHR technology to improve patient care.
31. Q: What is the purpose of a consent form? ANSWER To document
patient permission for treatment, release of information, or participation in
research.
32. Q: What is copy and paste in EHR documentation? ANSWER The
practice of duplicating previously documented information into a new entry,
which can lead to errors.
33. Q: What is chart tracking? ANSWER A system to monitor the location
and movement of health records.
34. Q: What is loose filing? ANSWER The process of adding documents to
health records after discharge.
35. Q: What is terminal digit filing? ANSWER A filing system that uses the
last digits of the medical record number to organize records.
36. Q: What is straight numerical filing? ANSWER A filing system where
records are arranged in ascending numerical order.
37. Q: What is alphabetic filing? ANSWER A filing system that organizes
records by patient last name.
38. Q: What is the primary advantage of terminal digit filing? ANSWER
Even distribution of records and workload across file areas.
39. Q: What is a file expansion rate? ANSWER The percentage increase in
the number of records over a specific period.
40. Q: What is record circulation? ANSWER The movement of health
records from storage to points of use and back.
