HIM Final Exam (Part 2) Questions And
Answers10
A group of reasonably preventable conditions that patients do not have upon admission to a
hospital, but which develop during the hospital stay - ANSWERS -Hospital-acquired conditions
The overall goal of documentation standards is: - ANSWERS -To ensure what is documented in
the health record is complete and accurately reflects the treatment provided to the patient
A hospital that participates in the Medicare and Medicaid programs must follow: - ANSWERS -
The Conditions of Participation
When defining its legal health record, a healthcare provider organization must do which of the
following? - ANSWERS -Assess the legal environment
Which of the following is the health record component that addresses the patient's current
complaints and symptoms and lists the patient's past medical, personal, and family history? -
ANSWERS -Medical history
General documentation guidelines apply to: - ANSWERS -All categories of healthcare records
True or false: Health record entries should be documented at the time the services they
describe are rendered. - ANSWERS -True
True or false: Only individuals authorized by the organization's policies should be allowed to
enter documentation in the health record. - ANSWERS -True
, True or false: Auto-authentication is the preferred method of authentication. - ANSWERS -False
True or false: When an error is made, the erroneous information can be obliterated. - ANSWERS
-False
A patient's gender, phone number, address, next of kin, and insurance policy holder information
would be considered what kind of data? - ANSWERS -Administrative data
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records
are commonly found in which type of record - ANSWERS -Ambulatory record
What type of health records may contain family and caregiver input? - ANSWERS -Behavioral
health records
The ambulatory surgery record contains information most similar to which of the following? -
ANSWERS -Hospital operative records
Which group focuses solely on accreditation of rehabilitation programs and services? -
ANSWERS -CARF
Which type of health record contains information about the means by which the patient arrived
at the healthcare setting and documentation of care provided to stabilize the patient? -
ANSWERS -Emergency care
A patient's registration forms, personal property list, RAI, care plan, and discharge or transfer
documentation would be found most frequently in which type of health record? - ANSWERS -
Long-term care
Which of the following would not be found in a physical exam? - ANSWERS -General condition
Answers10
A group of reasonably preventable conditions that patients do not have upon admission to a
hospital, but which develop during the hospital stay - ANSWERS -Hospital-acquired conditions
The overall goal of documentation standards is: - ANSWERS -To ensure what is documented in
the health record is complete and accurately reflects the treatment provided to the patient
A hospital that participates in the Medicare and Medicaid programs must follow: - ANSWERS -
The Conditions of Participation
When defining its legal health record, a healthcare provider organization must do which of the
following? - ANSWERS -Assess the legal environment
Which of the following is the health record component that addresses the patient's current
complaints and symptoms and lists the patient's past medical, personal, and family history? -
ANSWERS -Medical history
General documentation guidelines apply to: - ANSWERS -All categories of healthcare records
True or false: Health record entries should be documented at the time the services they
describe are rendered. - ANSWERS -True
True or false: Only individuals authorized by the organization's policies should be allowed to
enter documentation in the health record. - ANSWERS -True
, True or false: Auto-authentication is the preferred method of authentication. - ANSWERS -False
True or false: When an error is made, the erroneous information can be obliterated. - ANSWERS
-False
A patient's gender, phone number, address, next of kin, and insurance policy holder information
would be considered what kind of data? - ANSWERS -Administrative data
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records
are commonly found in which type of record - ANSWERS -Ambulatory record
What type of health records may contain family and caregiver input? - ANSWERS -Behavioral
health records
The ambulatory surgery record contains information most similar to which of the following? -
ANSWERS -Hospital operative records
Which group focuses solely on accreditation of rehabilitation programs and services? -
ANSWERS -CARF
Which type of health record contains information about the means by which the patient arrived
at the healthcare setting and documentation of care provided to stabilize the patient? -
ANSWERS -Emergency care
A patient's registration forms, personal property list, RAI, care plan, and discharge or transfer
documentation would be found most frequently in which type of health record? - ANSWERS -
Long-term care
Which of the following would not be found in a physical exam? - ANSWERS -General condition
