CHIMA NCE DATA & EHR QUESTIONS
WITH CORRECT ANSWERS
An organization's legal health record definition must identify the
following regarding individually identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - ....ANSWER ...-d
It is best practice to establish a ____ when defining the legal health
record.
a. Policy
b. Master patient index
c. Health record matrix
d. Both a and c - ....ANSWER ...-d
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,The legal health record can only be comprised of documentation that
physically exists in an electronic system.
True/False - ....ANSWER ...-False
Which function is the first step in the creation of a patient's medical
record and initiates the flow of patient information within the EHR?
a. Analysis
b. Patient registration
c. Scheduling
d. Coding - ....ANSWER ...-b
Which of the following processes includes deficiency analysis and chart
completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - ....ANSWER ...-d
Malpractice cases generally fall into the category of _____.
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, a. Negligence torts
b. Intentional torts
c. Fraud cases
d. Criminal cases - ....ANSWER ...-a
In a negligence case, a physician will be held to a standard of providing
care that reflects what is called _____ care.
a. Minimal
b. Optimal
c. Maximum
d. Reasonable - ....ANSWER ...-d
A physician who fails to treat a patient who is brought to him or her for
care is guilty of _____.
a. Malfeasance
b. Misfeasance
c. Nonfeasance
...COPYRIGHT ©️ 2025... ALL RIGHTS RESERVED... 3
WITH CORRECT ANSWERS
An organization's legal health record definition must identify the
following regarding individually identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - ....ANSWER ...-d
It is best practice to establish a ____ when defining the legal health
record.
a. Policy
b. Master patient index
c. Health record matrix
d. Both a and c - ....ANSWER ...-d
...COPYRIGHT ©️ 2025... ALL RIGHTS RESERVED... 1
,The legal health record can only be comprised of documentation that
physically exists in an electronic system.
True/False - ....ANSWER ...-False
Which function is the first step in the creation of a patient's medical
record and initiates the flow of patient information within the EHR?
a. Analysis
b. Patient registration
c. Scheduling
d. Coding - ....ANSWER ...-b
Which of the following processes includes deficiency analysis and chart
completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - ....ANSWER ...-d
Malpractice cases generally fall into the category of _____.
...COPYRIGHT ©️ 2025... ALL RIGHTS RESERVED... 2
, a. Negligence torts
b. Intentional torts
c. Fraud cases
d. Criminal cases - ....ANSWER ...-a
In a negligence case, a physician will be held to a standard of providing
care that reflects what is called _____ care.
a. Minimal
b. Optimal
c. Maximum
d. Reasonable - ....ANSWER ...-d
A physician who fails to treat a patient who is brought to him or her for
care is guilty of _____.
a. Malfeasance
b. Misfeasance
c. Nonfeasance
...COPYRIGHT ©️ 2025... ALL RIGHTS RESERVED... 3