HIM 1000-TEST 2 | QUESTIONS AND ANSWERS | 2026 UPDATE | WITH COMPLETE
SOLUTION
Signature legend - (ANSWER)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.
False - (ANSWER)Medicare Conditions of Participation require hospitals to retain medical records for a
period of no less than five years.
True - (ANSWER)Health care providers are responsible for documenting care and treatment to prove
that patient care was provided.
True - (ANSWER)The primary purpose of the patient record is to provide continuity of care.
jacket film - (ANSWER)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
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. - (ANSWER)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.
countersignature - (ANSWER)A form of authentication by an individual in addition to the signature by
the original author is known as a(n)
audit trail - (ANSWER)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?
, HIM 1000-TEST 2 | QUESTIONS AND ANSWERS | 2026 UPDATE | WITH COMPLETE
SOLUTION
provisional diagnosis - (ANSWER)An admission clerk must obtain the reason for the admission when
processing a hospital inpatient; this is called the:
the total number of discharges in the period - (ANSWER)To calculate the delinquent record rate,
divide the total number of delinquent records by:
True - (ANSWER)A patient record serves as a business record for the patient encounter and contains
administrative and clinical data.
every hour - (ANSWER)The abbreviation q.h. means:
true - (ANSWER)A signature legend identifies the author of a record entry by full signature when
initials are used in the patient record.
problem list - (ANSWER)Problem Number Diagnosis Date of Onset Date Resolved
1 Hypertension 12/05/XX
2 Diabetes 1/3/XX
3 Urinary Tract Infection 2/25/XX 3/10/XX
4 Respiratory Infection 4/5/XX 4/15/XX
The above information would be recorded as part of a
false - (ANSWER)Source oriented records consist of a database, problem list, and initial plan.
allow health care providers the opportunity to access patient information that was generated at other
locations. - (ANSWER)The ultimate goal of a regional health information organization (RHIO) is to:
SOLUTION
Signature legend - (ANSWER)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.
False - (ANSWER)Medicare Conditions of Participation require hospitals to retain medical records for a
period of no less than five years.
True - (ANSWER)Health care providers are responsible for documenting care and treatment to prove
that patient care was provided.
True - (ANSWER)The primary purpose of the patient record is to provide continuity of care.
jacket film - (ANSWER)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
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. - (ANSWER)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.
countersignature - (ANSWER)A form of authentication by an individual in addition to the signature by
the original author is known as a(n)
audit trail - (ANSWER)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?
, HIM 1000-TEST 2 | QUESTIONS AND ANSWERS | 2026 UPDATE | WITH COMPLETE
SOLUTION
provisional diagnosis - (ANSWER)An admission clerk must obtain the reason for the admission when
processing a hospital inpatient; this is called the:
the total number of discharges in the period - (ANSWER)To calculate the delinquent record rate,
divide the total number of delinquent records by:
True - (ANSWER)A patient record serves as a business record for the patient encounter and contains
administrative and clinical data.
every hour - (ANSWER)The abbreviation q.h. means:
true - (ANSWER)A signature legend identifies the author of a record entry by full signature when
initials are used in the patient record.
problem list - (ANSWER)Problem Number Diagnosis Date of Onset Date Resolved
1 Hypertension 12/05/XX
2 Diabetes 1/3/XX
3 Urinary Tract Infection 2/25/XX 3/10/XX
4 Respiratory Infection 4/5/XX 4/15/XX
The above information would be recorded as part of a
false - (ANSWER)Source oriented records consist of a database, problem list, and initial plan.
allow health care providers the opportunity to access patient information that was generated at other
locations. - (ANSWER)The ultimate goal of a regional health information organization (RHIO) is to:
