HIM 1000-TEST 2 | QUESTIONS AND ANSWERS | 2026
UPDATE | WITH COMPLETE SOLUTION
Ms. Smith analyzes patient records for deficiencies and determines that there
are entries that have been authenticated using initials. She needs to identify
the author of these entries to clarify information. She should reference the
____ to determine the full name of the author of the entries. Answer -
Signature legend
Medicare Conditions of Participation require hospitals to retain medical records
for a period of no less than five years. Answer - False
Health care providers are responsible for documenting care and treatment to
prove that patient care was provided. Answer - True
The primary purpose of the patient record is to provide continuity of care.
Answer - True
The HIM manager at Sunny View Hospital has decided that all records over two
years old will be microfilmed and that each patient record should be stored
individually after microfilming. This can be accomplished by using Answer -
jacket film
Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his
inpatient admission. At the time of the fall an incident report was completed.
He is now suing the hospital because he feels that the nurses were negligent
when caring for him. The following actions were taken by the facility.
, Determine which of these actions should NOT have occurred. Answer - A note
was entered in the patient record stating that an incident report was
completed.
A copy of the incident report was filed in the patient's record.
A form of authentication by an individual in addition to the signature by the
original author is known as a(n) Answer - countersignature
Sunny Valley Hospital has an electronic health record system. The health
information management (HIM) department has been asked by the quality
management department to monitor the number of times that providers make
corrections in patient documentation. Which of the following would provide
information that can be used by the HIM department to monitor the electronic
record transactions? Answer - audit trail
An admission clerk must obtain the reason for the admission when processing
a hospital inpatient; this is called the: Answer - provisional diagnosis
To calculate the delinquent record rate, divide the total number of delinquent
records by: Answer - the total number of discharges in the period
A patient record serves as a business record for the patient encounter and
contains administrative and clinical data. Answer - True
The abbreviation q.h. means: Answer - every hour
A signature legend identifies the author of a record entry by full signature
when initials are used in the patient record. Answer - true
UPDATE | WITH COMPLETE SOLUTION
Ms. Smith analyzes patient records for deficiencies and determines that there
are entries that have been authenticated using initials. She needs to identify
the author of these entries to clarify information. She should reference the
____ to determine the full name of the author of the entries. Answer -
Signature legend
Medicare Conditions of Participation require hospitals to retain medical records
for a period of no less than five years. Answer - False
Health care providers are responsible for documenting care and treatment to
prove that patient care was provided. Answer - True
The primary purpose of the patient record is to provide continuity of care.
Answer - True
The HIM manager at Sunny View Hospital has decided that all records over two
years old will be microfilmed and that each patient record should be stored
individually after microfilming. This can be accomplished by using Answer -
jacket film
Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his
inpatient admission. At the time of the fall an incident report was completed.
He is now suing the hospital because he feels that the nurses were negligent
when caring for him. The following actions were taken by the facility.
, Determine which of these actions should NOT have occurred. Answer - A note
was entered in the patient record stating that an incident report was
completed.
A copy of the incident report was filed in the patient's record.
A form of authentication by an individual in addition to the signature by the
original author is known as a(n) Answer - countersignature
Sunny Valley Hospital has an electronic health record system. The health
information management (HIM) department has been asked by the quality
management department to monitor the number of times that providers make
corrections in patient documentation. Which of the following would provide
information that can be used by the HIM department to monitor the electronic
record transactions? Answer - audit trail
An admission clerk must obtain the reason for the admission when processing
a hospital inpatient; this is called the: Answer - provisional diagnosis
To calculate the delinquent record rate, divide the total number of delinquent
records by: Answer - the total number of discharges in the period
A patient record serves as a business record for the patient encounter and
contains administrative and clinical data. Answer - True
The abbreviation q.h. means: Answer - every hour
A signature legend identifies the author of a record entry by full signature
when initials are used in the patient record. Answer - true
