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AHIMA RHIT Exam — 100 Practice Questions & Answers (2026 Version A & B)
VERSION A — Questions 1–50
Domain 1: Data Content, Structure & Information Governance
1. Which document in the health record provides a chronological summary of the patient's
hospitalization, including diagnoses, procedures, and discharge instructions?
A. History and physical
B. Discharge summary
C. Progress notes
D. Consultation report
Answer: B. The discharge summary provides a concise, chronological account of the
patient's stay, including admitting and final diagnoses, procedures performed, treatment
course, and discharge instructions .
2. According to Joint Commission standards, what is the maximum time frame within
which a history and physical examination must be completed after inpatient admission?
A. 48 hours
B. 12 hours
C. 24 hours
D. 72 hours
Answer: C. Joint Commission standards require that the history and physical examination be
completed within 24 hours of inpatient admission .
3. Which record format organizes documentation by each problem identified during the
patient's encounter?
A. Source-oriented record
B. Integrated record
C. Problem-oriented health record (POHR)
D. Chronological record
Answer: C. The problem-oriented health record, developed by Dr. Lawrence Weed, organizes
documentation around a patient's specific clinical problems .
4. In the SOAP note format, clinical observations such as vital signs, lab results, and
physical findings are documented in which section?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer: B. The Objective section contains measurable, observable clinical data including
vital signs, lab results, and physical examination findings .
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5. What is the primary purpose of the health record?
A. To bill insurance companies
B. To document patient care and support clinical decision-making
C. To advertise hospital services
D. To track hospital staff performance
Answer: B. The primary purpose of the health record is to document patient care, ensuring
continuity, supporting clinical decisions, and meeting legal requirements .
6. What is the primary purpose of an enterprise master patient index (EMPI)?
A. To store billing data
B. To link patient records across multiple facilities within a healthcare system
C. To track employee access
D. To schedule appointments
Answer: B. An EMPI uniquely identifies patients and links their records across multiple
facilities within a healthcare system .
7. A collection of data organized for rapid search and retrieval is called a:
A. Registry
B. Database
C. Data set
D. Data dictionary
Answer: B. A database is a collection of data organized for rapid search and retrieval .
8. Which of the following contains patient-identifiable information such as the patient's
name and address, date of birth, and health record number?
A. Master patient index
B. Data dictionary
C. Registry
D. Clinical data repository
Answer: A. The master patient index contains patient-identifiable information including
name, address, date of birth, and health record number .
9. The UHDDS does not require which of the following items?
A. Principal diagnosis
B. Family history
C. Significant procedures
D. Patient identifier
Answer: B. The UHDDS does not require family history. It requires principal diagnosis, other
diagnoses, significant procedures, and patient identifiers .
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10. The UHDDS defines "other diagnosis" as:
A. All conditions that coexist at the time of admission
B. Conditions that develop after admission
C. Only chronic conditions
D. Only surgical conditions
Answer: A. The UHDDS defines other diagnosis as all conditions that coexist at the time of
admission, or that develop subsequently, and that affect patient care .
11. The federally mandated resident assessment instrument used in long-term care
facilities consists of three basic components: the new care area assessments, utilization
guidelines, and the:
A. OASIS
B. MDS or minimum data set
C. IRF-PAI
D. UACDS
Answer: B. The Minimum Data Set (MDS) is one of the three basic components of the
resident assessment instrument used in long-term care facilities .
12. A qualitative review of a health record reveals that the H&P for a patient admitted on
June 26 was performed on June 30 and transcribed on July 1. Which statement is true?
A. The H&P is compliant because it was performed
B. Completion and charting of H&P indicates noncompliance with JC standards; H&P must be
completed within 24 hours
C. The H&P is compliant because it was transcribed
D. The H&P is exempt from time requirements
Answer: B. JC standards require the H&P to be completed within 24 hours of admission.
Performance on June 30 (four days after admission) is noncompliant .
13. In an acute care hospital, a complete history and physical may not be required for a
new admission when:
A. The patient refuses
B. A legible copy of a recent H&P performed in the attending physician's office is available
C. The patient is admitted on a weekend
D. The patient has insurance
Answer: B. A complete H&P may not be required when a legible copy of a recent H&P
performed in the attending physician's office is available .
14. The specifications for the values acceptable for specific data fields is referred to as:
A. Data standards
B. Data dictionary
AHIMA RHIT Exam — 100 Practice Questions & Answers (2026 Version A & B)
VERSION A — Questions 1–50
Domain 1: Data Content, Structure & Information Governance
1. Which document in the health record provides a chronological summary of the patient's
hospitalization, including diagnoses, procedures, and discharge instructions?
A. History and physical
B. Discharge summary
C. Progress notes
D. Consultation report
Answer: B. The discharge summary provides a concise, chronological account of the
patient's stay, including admitting and final diagnoses, procedures performed, treatment
course, and discharge instructions .
2. According to Joint Commission standards, what is the maximum time frame within
which a history and physical examination must be completed after inpatient admission?
A. 48 hours
B. 12 hours
C. 24 hours
D. 72 hours
Answer: C. Joint Commission standards require that the history and physical examination be
completed within 24 hours of inpatient admission .
3. Which record format organizes documentation by each problem identified during the
patient's encounter?
A. Source-oriented record
B. Integrated record
C. Problem-oriented health record (POHR)
D. Chronological record
Answer: C. The problem-oriented health record, developed by Dr. Lawrence Weed, organizes
documentation around a patient's specific clinical problems .
4. In the SOAP note format, clinical observations such as vital signs, lab results, and
physical findings are documented in which section?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer: B. The Objective section contains measurable, observable clinical data including
vital signs, lab results, and physical examination findings .
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5. What is the primary purpose of the health record?
A. To bill insurance companies
B. To document patient care and support clinical decision-making
C. To advertise hospital services
D. To track hospital staff performance
Answer: B. The primary purpose of the health record is to document patient care, ensuring
continuity, supporting clinical decisions, and meeting legal requirements .
6. What is the primary purpose of an enterprise master patient index (EMPI)?
A. To store billing data
B. To link patient records across multiple facilities within a healthcare system
C. To track employee access
D. To schedule appointments
Answer: B. An EMPI uniquely identifies patients and links their records across multiple
facilities within a healthcare system .
7. A collection of data organized for rapid search and retrieval is called a:
A. Registry
B. Database
C. Data set
D. Data dictionary
Answer: B. A database is a collection of data organized for rapid search and retrieval .
8. Which of the following contains patient-identifiable information such as the patient's
name and address, date of birth, and health record number?
A. Master patient index
B. Data dictionary
C. Registry
D. Clinical data repository
Answer: A. The master patient index contains patient-identifiable information including
name, address, date of birth, and health record number .
9. The UHDDS does not require which of the following items?
A. Principal diagnosis
B. Family history
C. Significant procedures
D. Patient identifier
Answer: B. The UHDDS does not require family history. It requires principal diagnosis, other
diagnoses, significant procedures, and patient identifiers .
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10. The UHDDS defines "other diagnosis" as:
A. All conditions that coexist at the time of admission
B. Conditions that develop after admission
C. Only chronic conditions
D. Only surgical conditions
Answer: A. The UHDDS defines other diagnosis as all conditions that coexist at the time of
admission, or that develop subsequently, and that affect patient care .
11. The federally mandated resident assessment instrument used in long-term care
facilities consists of three basic components: the new care area assessments, utilization
guidelines, and the:
A. OASIS
B. MDS or minimum data set
C. IRF-PAI
D. UACDS
Answer: B. The Minimum Data Set (MDS) is one of the three basic components of the
resident assessment instrument used in long-term care facilities .
12. A qualitative review of a health record reveals that the H&P for a patient admitted on
June 26 was performed on June 30 and transcribed on July 1. Which statement is true?
A. The H&P is compliant because it was performed
B. Completion and charting of H&P indicates noncompliance with JC standards; H&P must be
completed within 24 hours
C. The H&P is compliant because it was transcribed
D. The H&P is exempt from time requirements
Answer: B. JC standards require the H&P to be completed within 24 hours of admission.
Performance on June 30 (four days after admission) is noncompliant .
13. In an acute care hospital, a complete history and physical may not be required for a
new admission when:
A. The patient refuses
B. A legible copy of a recent H&P performed in the attending physician's office is available
C. The patient is admitted on a weekend
D. The patient has insurance
Answer: B. A complete H&P may not be required when a legible copy of a recent H&P
performed in the attending physician's office is available .
14. The specifications for the values acceptable for specific data fields is referred to as:
A. Data standards
B. Data dictionary
