Alabama Certified Health Information
Technician Complete Exam Preparation
2026/2027 – Complete Exam-Style Questions
with Correct Answers & Detailed Rationales |
Verified & Reliable
1.
A hospital is implementing an enterprise-wide information
governance program. Which activity BEST demonstrates
information governance rather than routine records
management?
A. Filing discharged patient records according to established
retention schedules
B. Assigning deficiency codes to incomplete medical records
C. Establishing organizational accountability for the quality,
availability, integrity, and appropriate use of health information
D. Scanning paper documents into the electronic health record
Correct answer: C
Information governance is the organization-wide framework for
managing information as a strategic asset throughout its
lifecycle. It encompasses accountability, quality, security,
,availability, privacy, retention, and appropriate use. Filing,
deficiency processing, and scanning are important HIM
activities, but they are narrower operational functions rather
than the overarching governance process.
2.
An HIM department discovers that the same patient has three
medical record numbers because registration staff used
different demographic information at separate encounters.
What is the MOST appropriate initial HIM response?
A. Delete two of the medical record numbers immediately
B. Merge the records according to the organization's approved
identity-management procedure
C. Assign a new medical record number to the patient
D. Keep all three records separate until the patient requests
consolidation
Correct answer: B
Duplicate medical record numbers create patient-safety and
data-integrity risks. The organization should use its approved
MPI duplicate-management procedure to validate identity and
merge or otherwise reconcile duplicate records appropriately.
Simply deleting records can destroy the audit trail and
potentially eliminate information that must be retained.
3.
,Which data characteristic is MOST directly concerned with
whether information accurately represents the patient's actual
clinical condition?
A. Timeliness
B. Validity
C. Completeness
D. Accessibility
Correct answer: B
Validity concerns whether data correctly represents the
intended attribute or condition and conforms to defined
requirements. Timeliness addresses whether data are available
when needed, completeness concerns whether required
elements are present, and accessibility concerns authorized
availability.
4.
A physician documents that a patient has “possible pneumonia”
in an inpatient admission. Under ICD-10-CM inpatient reporting
conventions, how should the condition generally be handled?
A. It should always be coded as a confirmed pneumonia
diagnosis
B. It should never be reported
C. The uncertain diagnosis may be coded as if it existed at
, discharge when documented as such
D. Only the symptom that led to the admission may be coded
Correct answer: C
For inpatient hospital reporting, diagnoses documented at
discharge as probable, suspected, likely, questionable, or similar
uncertain terms may be coded as though they existed. This
differs from outpatient reporting, where uncertain diagnoses
are generally not coded as confirmed conditions.
5.
Which situation BEST illustrates a data governance problem?
A. A coder takes longer than average to complete a record
B. Two departments use different definitions for “active
patient” in enterprise reports
C. A physician signs a discharge summary two hours late
D. A scanner malfunctions during document capture
Correct answer: B
Data governance requires organizationally consistent
definitions, ownership, standards, and controls for information.
When departments use different definitions for the same data
element, enterprise reporting can produce conflicting results.
The other situations may be operational or workflow problems
without necessarily representing governance failures.
Technician Complete Exam Preparation
2026/2027 – Complete Exam-Style Questions
with Correct Answers & Detailed Rationales |
Verified & Reliable
1.
A hospital is implementing an enterprise-wide information
governance program. Which activity BEST demonstrates
information governance rather than routine records
management?
A. Filing discharged patient records according to established
retention schedules
B. Assigning deficiency codes to incomplete medical records
C. Establishing organizational accountability for the quality,
availability, integrity, and appropriate use of health information
D. Scanning paper documents into the electronic health record
Correct answer: C
Information governance is the organization-wide framework for
managing information as a strategic asset throughout its
lifecycle. It encompasses accountability, quality, security,
,availability, privacy, retention, and appropriate use. Filing,
deficiency processing, and scanning are important HIM
activities, but they are narrower operational functions rather
than the overarching governance process.
2.
An HIM department discovers that the same patient has three
medical record numbers because registration staff used
different demographic information at separate encounters.
What is the MOST appropriate initial HIM response?
A. Delete two of the medical record numbers immediately
B. Merge the records according to the organization's approved
identity-management procedure
C. Assign a new medical record number to the patient
D. Keep all three records separate until the patient requests
consolidation
Correct answer: B
Duplicate medical record numbers create patient-safety and
data-integrity risks. The organization should use its approved
MPI duplicate-management procedure to validate identity and
merge or otherwise reconcile duplicate records appropriately.
Simply deleting records can destroy the audit trail and
potentially eliminate information that must be retained.
3.
,Which data characteristic is MOST directly concerned with
whether information accurately represents the patient's actual
clinical condition?
A. Timeliness
B. Validity
C. Completeness
D. Accessibility
Correct answer: B
Validity concerns whether data correctly represents the
intended attribute or condition and conforms to defined
requirements. Timeliness addresses whether data are available
when needed, completeness concerns whether required
elements are present, and accessibility concerns authorized
availability.
4.
A physician documents that a patient has “possible pneumonia”
in an inpatient admission. Under ICD-10-CM inpatient reporting
conventions, how should the condition generally be handled?
A. It should always be coded as a confirmed pneumonia
diagnosis
B. It should never be reported
C. The uncertain diagnosis may be coded as if it existed at
, discharge when documented as such
D. Only the symptom that led to the admission may be coded
Correct answer: C
For inpatient hospital reporting, diagnoses documented at
discharge as probable, suspected, likely, questionable, or similar
uncertain terms may be coded as though they existed. This
differs from outpatient reporting, where uncertain diagnoses
are generally not coded as confirmed conditions.
5.
Which situation BEST illustrates a data governance problem?
A. A coder takes longer than average to complete a record
B. Two departments use different definitions for “active
patient” in enterprise reports
C. A physician signs a discharge summary two hours late
D. A scanner malfunctions during document capture
Correct answer: B
Data governance requires organizationally consistent
definitions, ownership, standards, and controls for information.
When departments use different definitions for the same data
element, enterprise reporting can produce conflicting results.
The other situations may be operational or workflow problems
without necessarily representing governance failures.
