Health Information Management – Exam Review 2026 – Study Guide
and Practice Questions
Health Information - correct answer ✔✔ info pertaining to mental health, physical health,
condition or infirmity.
Health Information Custodian - correct answer ✔✔ person or organization responsible for
managing health information
Health Record - correct answer ✔✔ Documentation related to or a collection of documents
related to a health-care client.
What is a health record used for? - correct answer ✔✔ To maintain and manage health
information
EMR - correct answer ✔✔ narrow view of a patients medical history
EHR - correct answer ✔✔ comprehensive report of patient's overall health
EMR advantages over a paper record - correct answer ✔✔ 1. rapid access to information 2.safer
and reliable prescribing 3.Enhancied privacy and security of data 4.accurate, up-to-date,
complete information
6 ways to Maintain EMR security - correct answer ✔✔ 1. Protecting screen from unauthorized
viewers 2.Using and updating passwords regularly 3.Never share password 4.Fob(randomly
generated security codes) 5.Implementing a two-step ID process 6.Audit logging to record usage
of all users
, What is purging a chart? - correct answer ✔✔ review,reorganize, removing outdated
information no longer actively needed
When would an MOA Purge? - correct answer ✔✔ When charts are ten years-old, file has never
been purged or patient has passed away
What is a chart? - correct answer ✔✔ A chart is a patient's medical history
What are 6 components to a medical chart? - correct answer ✔✔ 1.Demographic data 2.
recorded encounters 3. Information entered with an appropriate date 4. relevant History
5.Safely and properly store 6.Chart must be kept confidential
What are 9 common medical records found in a patient's chart? - correct answer ✔✔ 1.History
Interview sheet 2.CPP(cumulative patient profile 3.List of allergies 4.Encounter record 5.Physical
assessment 6.Lab sheets 7.Operative reports 8.Consultation reports/letters 9. Miscellaneous
History Interview - correct answer ✔✔ questionnaire client fills out upon first visit
CPP (cumulative patient profile) - correct answer ✔✔ answers to history questionnaire. Emr CPP
showcases patient's entire health history.
List of allergies - correct answer ✔✔ medications,foods, chemicals
Encounter Record - correct answer ✔✔ Each time there's an encounter with health-care
provider. EMR template SOAP S=subject O=objective A= Examiners assessment P= Plan for the
client
Physical Assessment - correct answer ✔✔ full examination of patient, annual or symptom
driven.
and Practice Questions
Health Information - correct answer ✔✔ info pertaining to mental health, physical health,
condition or infirmity.
Health Information Custodian - correct answer ✔✔ person or organization responsible for
managing health information
Health Record - correct answer ✔✔ Documentation related to or a collection of documents
related to a health-care client.
What is a health record used for? - correct answer ✔✔ To maintain and manage health
information
EMR - correct answer ✔✔ narrow view of a patients medical history
EHR - correct answer ✔✔ comprehensive report of patient's overall health
EMR advantages over a paper record - correct answer ✔✔ 1. rapid access to information 2.safer
and reliable prescribing 3.Enhancied privacy and security of data 4.accurate, up-to-date,
complete information
6 ways to Maintain EMR security - correct answer ✔✔ 1. Protecting screen from unauthorized
viewers 2.Using and updating passwords regularly 3.Never share password 4.Fob(randomly
generated security codes) 5.Implementing a two-step ID process 6.Audit logging to record usage
of all users
, What is purging a chart? - correct answer ✔✔ review,reorganize, removing outdated
information no longer actively needed
When would an MOA Purge? - correct answer ✔✔ When charts are ten years-old, file has never
been purged or patient has passed away
What is a chart? - correct answer ✔✔ A chart is a patient's medical history
What are 6 components to a medical chart? - correct answer ✔✔ 1.Demographic data 2.
recorded encounters 3. Information entered with an appropriate date 4. relevant History
5.Safely and properly store 6.Chart must be kept confidential
What are 9 common medical records found in a patient's chart? - correct answer ✔✔ 1.History
Interview sheet 2.CPP(cumulative patient profile 3.List of allergies 4.Encounter record 5.Physical
assessment 6.Lab sheets 7.Operative reports 8.Consultation reports/letters 9. Miscellaneous
History Interview - correct answer ✔✔ questionnaire client fills out upon first visit
CPP (cumulative patient profile) - correct answer ✔✔ answers to history questionnaire. Emr CPP
showcases patient's entire health history.
List of allergies - correct answer ✔✔ medications,foods, chemicals
Encounter Record - correct answer ✔✔ Each time there's an encounter with health-care
provider. EMR template SOAP S=subject O=objective A= Examiners assessment P= Plan for the
client
Physical Assessment - correct answer ✔✔ full examination of patient, annual or symptom
driven.
