CHIMA EXAM PREP - Health Information
Management / Health Information
Systems / Moving Towards an EHR
Define Clinical - ✔️✔️To facilitate and promote continuity and quality of care and serve
as a communication tool amongst care providers
Capture and collection phase of the Health Information Lifecycle
Define Education - ✔️✔️To support teaching and continuing education programs for
medical and other students, interns, and residents affiliated with a university or other
educational institution
Capture and collection phase of the Health Information Lifecycle
Define Legal Events - ✔️✔️To provide information in cases of litigation, including
criminal proceedings, custody battles and appeals for privileges
If a healthcare organization plans to exchange health information with other
organizations, the data created must meet what international standard?
a. CIHI
b. EHRS BluePrint Version 2
c. IHE Cross Document Sharing profile
d. Heath Level Seven International (HL7) - ✔️✔️d. Heath Level Seven International
(HL7)
An example of unstructured data is:
a. an electrocardiogram
b. digital heart sounds
c. ultrasound data
d. transcribed reports - ✔️✔️d. transcribed reports
An example of discrete, structured data is:
a. free-text boxes on-line
b. nuclear medicine stored as bit mapped
c. medication orders
d. cardiac catheterizations - ✔️✔️c. medication orders
, What should be developed for direct charting, voice recognition or transcribed
documents to promote the consistent use of language and expression?
a. Organization-specific lists of abbreviations, acronyms and symbols
b. A staff education program on implications to patient safety of misinterpreted truncated
words or characters
c. Templates
d. Data Dictionary - ✔️✔️c. Templates
Acceptable authentication for electronic records includes the author using a/an:
a. digital signature or computer key
b. template to track changes
c. initials with corresponding signature legend
d. audit trail - ✔️✔️a. digital signature or computer key
Which of the following in NOT an objective component of SOAP
a. Patients chief complaint
b. Blood Pressure
c. Previous lab or diagnostic test results
d. Vital Sign Measurements - ✔️✔️a. Patients chief complaint
What is the "retraction" as it pertains to health Information?
a. Removing a document from one individual's records and posting it to another record
b. A late entry that provides additional information about a previous entry
c. Deleting duplicate health records within a master patient index (MPI)
d. Separating health records that were inadvertently merged within an MPI - ✔️✔️a.
Removing a document from one individual's records and posting it to another record
Which stage is stated to be the most important stage in the health information lifecycle?
a. Maintenance and protection
b. Information management planning
c. Evaluation
d. Capture and collection - ✔️✔️b. Information management planning
Which stage of the health information life cycle ensures that necessary safeguards are
in place for the appropriate use of patient information?
a. Governance and accountability
b. Capture and collection
c. Disposition
d. Access, use and dissemination - ✔️✔️a. Governance and accountability
Management / Health Information
Systems / Moving Towards an EHR
Define Clinical - ✔️✔️To facilitate and promote continuity and quality of care and serve
as a communication tool amongst care providers
Capture and collection phase of the Health Information Lifecycle
Define Education - ✔️✔️To support teaching and continuing education programs for
medical and other students, interns, and residents affiliated with a university or other
educational institution
Capture and collection phase of the Health Information Lifecycle
Define Legal Events - ✔️✔️To provide information in cases of litigation, including
criminal proceedings, custody battles and appeals for privileges
If a healthcare organization plans to exchange health information with other
organizations, the data created must meet what international standard?
a. CIHI
b. EHRS BluePrint Version 2
c. IHE Cross Document Sharing profile
d. Heath Level Seven International (HL7) - ✔️✔️d. Heath Level Seven International
(HL7)
An example of unstructured data is:
a. an electrocardiogram
b. digital heart sounds
c. ultrasound data
d. transcribed reports - ✔️✔️d. transcribed reports
An example of discrete, structured data is:
a. free-text boxes on-line
b. nuclear medicine stored as bit mapped
c. medication orders
d. cardiac catheterizations - ✔️✔️c. medication orders
, What should be developed for direct charting, voice recognition or transcribed
documents to promote the consistent use of language and expression?
a. Organization-specific lists of abbreviations, acronyms and symbols
b. A staff education program on implications to patient safety of misinterpreted truncated
words or characters
c. Templates
d. Data Dictionary - ✔️✔️c. Templates
Acceptable authentication for electronic records includes the author using a/an:
a. digital signature or computer key
b. template to track changes
c. initials with corresponding signature legend
d. audit trail - ✔️✔️a. digital signature or computer key
Which of the following in NOT an objective component of SOAP
a. Patients chief complaint
b. Blood Pressure
c. Previous lab or diagnostic test results
d. Vital Sign Measurements - ✔️✔️a. Patients chief complaint
What is the "retraction" as it pertains to health Information?
a. Removing a document from one individual's records and posting it to another record
b. A late entry that provides additional information about a previous entry
c. Deleting duplicate health records within a master patient index (MPI)
d. Separating health records that were inadvertently merged within an MPI - ✔️✔️a.
Removing a document from one individual's records and posting it to another record
Which stage is stated to be the most important stage in the health information lifecycle?
a. Maintenance and protection
b. Information management planning
c. Evaluation
d. Capture and collection - ✔️✔️b. Information management planning
Which stage of the health information life cycle ensures that necessary safeguards are
in place for the appropriate use of patient information?
a. Governance and accountability
b. Capture and collection
c. Disposition
d. Access, use and dissemination - ✔️✔️a. Governance and accountability
