AHIMA RHIA FINAL EXAM QUESTIONS AND
ANSWERS GRADED A+ ASSURED SUCCESS
NEW UPDATE 2025/2026, Exams of Nursing
Which of the following is a graphical display of the relationships between tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS Correct Answer: C
An entity relationship diagram (ERD) is used to describe how the tables work together. The
diagram is a graphic representation of the entities, attributes, and relationships that are part of
a database and is a data modeling tool (White 2016a, 46).
When a healthcare entity destroys health records after the acceptable retention period has
been met, a certificate of destruction is created. How long must the healthcare entity maintain
the certificate of destruction?
a. Two years
b. Five years
c. Ten years
d. Permanently Correct Answer: D
Appropriate documentation of health record destruction must be maintained permanently no
matter how the process is carried out. This documentation usually takes the form of a certificate
of destruction (Fahrenholz 2017b, 108).
What is a primary purpose for documenting and maintaining health records?
a. Effective communication among caregivers for continuity of care
b. Substantiate claims for reimbursement
c. Provide evidence for malpractice lawsuits
d. Contribute to medical science Correct Answer: A
1|Page
,Federal and state statutes, licensing requirements, and accreditation standards provide
minimum guidelines to ensure accurate and complete documentation. Such documentation
facilitates effective communication among caregivers to provide continuity of patient care,
which is its primary purpose (Fahrenholz 2017e, 1).
A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The
patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is
the correct root operation?
a. Destruction
b. Extirpation
c. Fragmentation
d. Release Correct Answer: B
The correct root operation is extirpation—taking or cutting out solid matter from a body part.
The earlier lithotripsy would have been fragmentation but was not successful in removing the
calculus (Kuehn and Jorwic 2019, 85-86).
According to the Medicare Conditions of Participation, how long must health records be
retained?
a. Two years
b. Five years
c. Ten years
d. Permanently Correct Answer: B
A health record must be maintained for every individual evaluated or treated in the hospital.
Health records must be retained in their original or legally reproduced form for a period of at
least 5 years (Fahrenholz 2017b, 106).
A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler
on a(n):
a. Diabetes registry
b. Cancer registry
c. Immunization registry
d. Trauma registry Correct Answer: C
2|Page
,Immunization registries usually have the purpose of increasing the number of infants and
children who receive proper immunizations at the proper intervals. To accomplish this goal, they
collect information within a particular geographic area about children and their immunization
status (Sharp and Madlock-Brown 2016, 180).
Unstructured data may be preferred over structured data because:
a. It does not require processing
b. It provides greater detail
c. Clinicians know how to enter it
d. It is more complete Correct Answer: B
Unstructured data is often preferred over structured data because it enables providers to
document details and nuance that are usually not available with structured data (Biedermann
and Dolezel 2017, 159).
Appropriate documentation of health record destruction must be maintained permanently no
matter how the process is carried out. This documentation usually takes the form of a:
a. Policy of destruction
b. Retention schedule
c. Regulation schedule
d. Certificate of destruction Correct Answer: D
Appropriate documentation of health record destruction must be maintained permanently no
matter how the process is carried out. This documentation usually takes the form of a certificate
of destruction (Fahrenholz 2017b, 108).
The leadership and organizational structures, policies, procedures, technology, and controls that
ensure that patient and other enterprise data and information sustain and extend the entity's
mission and strategies, deliver value, comply with laws and regulations, minimize risk to all
stakeholders, and advance the public good is called:
a. Information asset management
b. Information management
c. Information governance
d. Enterprise information management Correct Answer: C
3|Page
, Information governance is defined as ensuring leadership and organizational practices,
resources, and controls for effective, compliant, and ethical stewardship of information assets to
enable best clinical and business practices and serve patients, stakeholders, and the public good
(Johns 2016, 79).
Reviewing a health record for missing signatures and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing Correct Answer: A
Analysis is a review of the health record for completeness and accuracy. HIM personnel can
remind providers to complete items in the record and to sign orders and progress (Reynolds and
Sharp 2016, 123).
Which of the following is a business role with major responsibilities that include identifying the
specific data needed to operate business processes, recording metadata, and identifying and
enforcing quality standards?
a. Chief data officer
b. Data definition steward
c. Data production steward
d. Subject matter expert Correct Answer: B
Data definition stewards function in a business, as opposed to a technical role; major
responsibilities include identifying the specific data needed to operate business processes,
recording business definitions and metadata, identifying and enforcing quality standards,
communicating data issue concerns, and communicating new or changed business
requirements (Johns 2016, 93).
A collection of data that is organized so its contents can be easily accessed, managed, and
updated is called a:
a. Spreadsheet
b. Database
c. File
d. Data table Correct Answer: B
4|Page
ANSWERS GRADED A+ ASSURED SUCCESS
NEW UPDATE 2025/2026, Exams of Nursing
Which of the following is a graphical display of the relationships between tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS Correct Answer: C
An entity relationship diagram (ERD) is used to describe how the tables work together. The
diagram is a graphic representation of the entities, attributes, and relationships that are part of
a database and is a data modeling tool (White 2016a, 46).
When a healthcare entity destroys health records after the acceptable retention period has
been met, a certificate of destruction is created. How long must the healthcare entity maintain
the certificate of destruction?
a. Two years
b. Five years
c. Ten years
d. Permanently Correct Answer: D
Appropriate documentation of health record destruction must be maintained permanently no
matter how the process is carried out. This documentation usually takes the form of a certificate
of destruction (Fahrenholz 2017b, 108).
What is a primary purpose for documenting and maintaining health records?
a. Effective communication among caregivers for continuity of care
b. Substantiate claims for reimbursement
c. Provide evidence for malpractice lawsuits
d. Contribute to medical science Correct Answer: A
1|Page
,Federal and state statutes, licensing requirements, and accreditation standards provide
minimum guidelines to ensure accurate and complete documentation. Such documentation
facilitates effective communication among caregivers to provide continuity of patient care,
which is its primary purpose (Fahrenholz 2017e, 1).
A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The
patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is
the correct root operation?
a. Destruction
b. Extirpation
c. Fragmentation
d. Release Correct Answer: B
The correct root operation is extirpation—taking or cutting out solid matter from a body part.
The earlier lithotripsy would have been fragmentation but was not successful in removing the
calculus (Kuehn and Jorwic 2019, 85-86).
According to the Medicare Conditions of Participation, how long must health records be
retained?
a. Two years
b. Five years
c. Ten years
d. Permanently Correct Answer: B
A health record must be maintained for every individual evaluated or treated in the hospital.
Health records must be retained in their original or legally reproduced form for a period of at
least 5 years (Fahrenholz 2017b, 106).
A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler
on a(n):
a. Diabetes registry
b. Cancer registry
c. Immunization registry
d. Trauma registry Correct Answer: C
2|Page
,Immunization registries usually have the purpose of increasing the number of infants and
children who receive proper immunizations at the proper intervals. To accomplish this goal, they
collect information within a particular geographic area about children and their immunization
status (Sharp and Madlock-Brown 2016, 180).
Unstructured data may be preferred over structured data because:
a. It does not require processing
b. It provides greater detail
c. Clinicians know how to enter it
d. It is more complete Correct Answer: B
Unstructured data is often preferred over structured data because it enables providers to
document details and nuance that are usually not available with structured data (Biedermann
and Dolezel 2017, 159).
Appropriate documentation of health record destruction must be maintained permanently no
matter how the process is carried out. This documentation usually takes the form of a:
a. Policy of destruction
b. Retention schedule
c. Regulation schedule
d. Certificate of destruction Correct Answer: D
Appropriate documentation of health record destruction must be maintained permanently no
matter how the process is carried out. This documentation usually takes the form of a certificate
of destruction (Fahrenholz 2017b, 108).
The leadership and organizational structures, policies, procedures, technology, and controls that
ensure that patient and other enterprise data and information sustain and extend the entity's
mission and strategies, deliver value, comply with laws and regulations, minimize risk to all
stakeholders, and advance the public good is called:
a. Information asset management
b. Information management
c. Information governance
d. Enterprise information management Correct Answer: C
3|Page
, Information governance is defined as ensuring leadership and organizational practices,
resources, and controls for effective, compliant, and ethical stewardship of information assets to
enable best clinical and business practices and serve patients, stakeholders, and the public good
(Johns 2016, 79).
Reviewing a health record for missing signatures and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing Correct Answer: A
Analysis is a review of the health record for completeness and accuracy. HIM personnel can
remind providers to complete items in the record and to sign orders and progress (Reynolds and
Sharp 2016, 123).
Which of the following is a business role with major responsibilities that include identifying the
specific data needed to operate business processes, recording metadata, and identifying and
enforcing quality standards?
a. Chief data officer
b. Data definition steward
c. Data production steward
d. Subject matter expert Correct Answer: B
Data definition stewards function in a business, as opposed to a technical role; major
responsibilities include identifying the specific data needed to operate business processes,
recording business definitions and metadata, identifying and enforcing quality standards,
communicating data issue concerns, and communicating new or changed business
requirements (Johns 2016, 93).
A collection of data that is organized so its contents can be easily accessed, managed, and
updated is called a:
a. Spreadsheet
b. Database
c. File
d. Data table Correct Answer: B
4|Page
