1|Page
HIMT 1250 DOCUMENTATION FOR HEALTH
RECORDS FINAL EXAM REVIEW 2026-UPDATED
QUESTIONS AND ANSWERS
Long term care hospitals must meet requirements for _____________
and have an agreement with ____________ in order to receive
payments - correct-answer -Acute care hospitals, Medicare
The ___________ established the Common Clinical Data Set - correct-
answer -"ONC" Office of the National Coordinator
Documentation that supports that skilled services are medically
reasonable & necessary - correct-answer -Medical Necessity
Medicare Quality indicators are criteria that, if present in a patients
record, are likely to result in higher quality of care than if they are not
present - correct-answer -True
The Healthcare Effectiveness Data and Information Set contains
standard________________ - correct-answer -Performance Measures
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What provides a wide range of services to include nursing care, 24-hour
supervision, assistance with activities of daily living and rehabilitation
services such as physical, occupational, & speech therapy - correct-
answer -SNF Skilled Nursing Facilities
Under the centers for Medicare and Medicaid services Comprehensive
(CERT) Program which of the following is not a common documentation
error in the Ambulatory Care - correct-answer -History and physical
within 30 days
Which of the following is an unacceptable signature on a home health
plan of care - correct-answer -Stamped signature
which chapter of HCPCS would you find drugs administered
intravenously - correct-answer -J Codes
The objective of Rx-Norm is to normalize names of generic & brand
drugs and attach a __________ to that name - correct-answer -Rx-
Norm concept unique identifier
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The __________ is a snapshot of a patient's status & includes
everything from social issues to disease processes, as well as critical
paths & clinical pathways that focused on a specific disease process or
pathway - correct-answer -Care Plan
General written guidelines that dictate behavior & or direct & constrain
decision making within the organization are known as what - correct-
answer -Policies
Which Joint Commission survey methodology involves an evaluation
that follows the hospital experiences of past or current patients -
correct-answer -Tracer Methodology
______________questions are preferred to use in queries to avoid
limiting or leading provider responses - correct-answer -Open ended
The ______________ is a derived classification of the (WHO) world
health organization family of international classifications - correct-
answer -ICD-03
HIMT 1250 DOCUMENTATION FOR HEALTH
RECORDS FINAL EXAM REVIEW 2026-UPDATED
QUESTIONS AND ANSWERS
Long term care hospitals must meet requirements for _____________
and have an agreement with ____________ in order to receive
payments - correct-answer -Acute care hospitals, Medicare
The ___________ established the Common Clinical Data Set - correct-
answer -"ONC" Office of the National Coordinator
Documentation that supports that skilled services are medically
reasonable & necessary - correct-answer -Medical Necessity
Medicare Quality indicators are criteria that, if present in a patients
record, are likely to result in higher quality of care than if they are not
present - correct-answer -True
The Healthcare Effectiveness Data and Information Set contains
standard________________ - correct-answer -Performance Measures
,2|Page
What provides a wide range of services to include nursing care, 24-hour
supervision, assistance with activities of daily living and rehabilitation
services such as physical, occupational, & speech therapy - correct-
answer -SNF Skilled Nursing Facilities
Under the centers for Medicare and Medicaid services Comprehensive
(CERT) Program which of the following is not a common documentation
error in the Ambulatory Care - correct-answer -History and physical
within 30 days
Which of the following is an unacceptable signature on a home health
plan of care - correct-answer -Stamped signature
which chapter of HCPCS would you find drugs administered
intravenously - correct-answer -J Codes
The objective of Rx-Norm is to normalize names of generic & brand
drugs and attach a __________ to that name - correct-answer -Rx-
Norm concept unique identifier
, 3|Page
The __________ is a snapshot of a patient's status & includes
everything from social issues to disease processes, as well as critical
paths & clinical pathways that focused on a specific disease process or
pathway - correct-answer -Care Plan
General written guidelines that dictate behavior & or direct & constrain
decision making within the organization are known as what - correct-
answer -Policies
Which Joint Commission survey methodology involves an evaluation
that follows the hospital experiences of past or current patients -
correct-answer -Tracer Methodology
______________questions are preferred to use in queries to avoid
limiting or leading provider responses - correct-answer -Open ended
The ______________ is a derived classification of the (WHO) world
health organization family of international classifications - correct-
answer -ICD-03
