AHIMA RHIA FINAL EXAM QUESTIONS
AND ANSWERS GRADED A+ ASSURED
SUCCESS NEW UPDATE 2025/2026, Exams
of Nursing
1. Sally is the HIM director at Memorial Hospital and has been asked to compose a record
retention policy for the hospital. What should be her first consideration in determining how long
paper and electronic records must be retained?
a. The amount of space allocated for record filing and server set up
b. The number of paper records currently filed and the number of electronic files added on a
daily basis
c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and
standards
d. The cost of filing space and equipment
C
2. A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal
pain. The attending physician requested an upper GI series and laboratory evaluation of CBC
and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood
cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured
appendix was discovered. The chief complaint was:
a. Abdominal pain
b. Cholelithiasis
c. Exploratory laparoscopy
d. Ruptured appendix
A
3. Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge
summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is
missing from Mrs. Smith's health record?
a. Data accuracy
b. Data consistency
c. Data accessibility
d. Data comprehensiveness
B
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,4. The discharge summary must be completed within ________ after discharge for most
patients but within ________ for patients transferred to other facilities. Discharge summaries
are not always required for patients who were hospitalized for fewer than ________ hours.
a. 30 days, 48 hours, 24 hours
b. 14 days, 24 hours, 48 hours
c. 14 days, 48 hours, 24 hours
d. 30 days, 24 hours, 48 hours
D
5. Which of the following is an acceptable means of authenticating a record entry?
a. The physician's assistant electronically signs for the physician.
b. The HIM clerk electronically signs using the physician's login.
c. The charge nurse electronically signs for the physician.
d. The physician personally signs the entry electronically.
D
6. A method of documenting nurses' progress notes by recording only abnormal or unusual
findings or deviations from the prescribed plan of care is called:
a. Problem-oriented progress notes
b. Charting by exception
c. Consultative notations
d. Open charting
B
7. In a long-term care setting, these are problem-oriented frameworks for additional patient
assessment based on problem identification items (triggered conditions):
a. Resident Assessment Protocols (RAPs)
b. Resident Assessment Instrument (RAI)
c. Utilization Guidelines (UG)
d. Minimum Data Sets (MDS)
A
8. HIM departments may be the hub of identifying, mitigating, and correcting master patient
index (MPI) errors. Often that information is not shared with other departments within the
healthcare entity. After identifying procedural problems that contribute to the creation of the
MPI errors, which department should the MPI manager work with to correct these procedural
problems?
a. Administration
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,b. Registration or patient access
c. Risk management
d. Radiology and laboratory
B
9. Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that
all documents are complete and signatures are present. This is an example of a:
a. Closed review
b. Qualitative review
c. Concurrent review
d. Delinquent review
C
10. What type of information makes it easy for hospitals to compare and combine the contents
of multiple patient health records?
a. Administrative information
b. Demographic information
c. Progress notes
d. Uniform data sets
D
11. The data elements in a patient's automated laboratory result are examples of:
a. Unstructured data
b. Free-text data
c. Financial data
d. Structured data
D
12. Which of the following materials are required elements in an emergency care record?
a. Patient's instructions at discharge and a complete medical history
b. Time and means of the patient's arrival, treatment rendered, and instructions at discharge
c. Time and means of the patient's arrival, patient's complete medical history, and instructions
at discharge
d. Treatment rendered, instructions at discharge, and the patient's complete medical history
B
13. In assessing the quality of care given to patients with diabetes mellitus, the quality team
collects data regarding blood sugar levels on admission and on discharge. These data are called
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, a(n):
a. Indicator
b. Measurement
c. Assessment
d. Outcome
A
14. Sue is updating the data dictionary for her organization. In this data dictionary, the data
element name is considered which of the following?
a. Master data
b. Metadata
c. Structured data
d. Unstructured data
B
15. Which of the following is used by a long-term care facility to gather information about
specific health status factors and includes information about specific risk factors in the
resident's care?
a. Case management
b. Minimum Data Set
c. Outcomes and assessment information set
d. Core measure abstracting
B
16. Dr. Collins admitted John Baker to University Hospital. Blue Cross Insurance will pay John's
hospital bill. Upon discharge from the hospital, who owns John's health record?
a. John
b. Blue Cross
c. University Hospital
d. Dr. Collins
C
17. What should be done about the email exchange between Jane Smith and her doctor, Dr.
Ward, regarding Jane's concerns about an abnormal lab result and the doctor's response
providing explanations and treatment options?
a. Since this is an email correspondence, the facility has no responsibility to keep it as part of
the patient's medical record.
b. Since this email correspondence relates to communication between a physician and a patient
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AND ANSWERS GRADED A+ ASSURED
SUCCESS NEW UPDATE 2025/2026, Exams
of Nursing
1. Sally is the HIM director at Memorial Hospital and has been asked to compose a record
retention policy for the hospital. What should be her first consideration in determining how long
paper and electronic records must be retained?
a. The amount of space allocated for record filing and server set up
b. The number of paper records currently filed and the number of electronic files added on a
daily basis
c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and
standards
d. The cost of filing space and equipment
C
2. A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal
pain. The attending physician requested an upper GI series and laboratory evaluation of CBC
and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood
cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured
appendix was discovered. The chief complaint was:
a. Abdominal pain
b. Cholelithiasis
c. Exploratory laparoscopy
d. Ruptured appendix
A
3. Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge
summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is
missing from Mrs. Smith's health record?
a. Data accuracy
b. Data consistency
c. Data accessibility
d. Data comprehensiveness
B
1|Page
,4. The discharge summary must be completed within ________ after discharge for most
patients but within ________ for patients transferred to other facilities. Discharge summaries
are not always required for patients who were hospitalized for fewer than ________ hours.
a. 30 days, 48 hours, 24 hours
b. 14 days, 24 hours, 48 hours
c. 14 days, 48 hours, 24 hours
d. 30 days, 24 hours, 48 hours
D
5. Which of the following is an acceptable means of authenticating a record entry?
a. The physician's assistant electronically signs for the physician.
b. The HIM clerk electronically signs using the physician's login.
c. The charge nurse electronically signs for the physician.
d. The physician personally signs the entry electronically.
D
6. A method of documenting nurses' progress notes by recording only abnormal or unusual
findings or deviations from the prescribed plan of care is called:
a. Problem-oriented progress notes
b. Charting by exception
c. Consultative notations
d. Open charting
B
7. In a long-term care setting, these are problem-oriented frameworks for additional patient
assessment based on problem identification items (triggered conditions):
a. Resident Assessment Protocols (RAPs)
b. Resident Assessment Instrument (RAI)
c. Utilization Guidelines (UG)
d. Minimum Data Sets (MDS)
A
8. HIM departments may be the hub of identifying, mitigating, and correcting master patient
index (MPI) errors. Often that information is not shared with other departments within the
healthcare entity. After identifying procedural problems that contribute to the creation of the
MPI errors, which department should the MPI manager work with to correct these procedural
problems?
a. Administration
2|Page
,b. Registration or patient access
c. Risk management
d. Radiology and laboratory
B
9. Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that
all documents are complete and signatures are present. This is an example of a:
a. Closed review
b. Qualitative review
c. Concurrent review
d. Delinquent review
C
10. What type of information makes it easy for hospitals to compare and combine the contents
of multiple patient health records?
a. Administrative information
b. Demographic information
c. Progress notes
d. Uniform data sets
D
11. The data elements in a patient's automated laboratory result are examples of:
a. Unstructured data
b. Free-text data
c. Financial data
d. Structured data
D
12. Which of the following materials are required elements in an emergency care record?
a. Patient's instructions at discharge and a complete medical history
b. Time and means of the patient's arrival, treatment rendered, and instructions at discharge
c. Time and means of the patient's arrival, patient's complete medical history, and instructions
at discharge
d. Treatment rendered, instructions at discharge, and the patient's complete medical history
B
13. In assessing the quality of care given to patients with diabetes mellitus, the quality team
collects data regarding blood sugar levels on admission and on discharge. These data are called
3|Page
, a(n):
a. Indicator
b. Measurement
c. Assessment
d. Outcome
A
14. Sue is updating the data dictionary for her organization. In this data dictionary, the data
element name is considered which of the following?
a. Master data
b. Metadata
c. Structured data
d. Unstructured data
B
15. Which of the following is used by a long-term care facility to gather information about
specific health status factors and includes information about specific risk factors in the
resident's care?
a. Case management
b. Minimum Data Set
c. Outcomes and assessment information set
d. Core measure abstracting
B
16. Dr. Collins admitted John Baker to University Hospital. Blue Cross Insurance will pay John's
hospital bill. Upon discharge from the hospital, who owns John's health record?
a. John
b. Blue Cross
c. University Hospital
d. Dr. Collins
C
17. What should be done about the email exchange between Jane Smith and her doctor, Dr.
Ward, regarding Jane's concerns about an abnormal lab result and the doctor's response
providing explanations and treatment options?
a. Since this is an email correspondence, the facility has no responsibility to keep it as part of
the patient's medical record.
b. Since this email correspondence relates to communication between a physician and a patient
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