HEALTH INFORMATION MANAGEMENT
EXAM STUDY GUIDE 2026 COMPLETE
QUESTIONS AND SOLUTIONS
◉Emergency Care. Answer: _____________ documentation includes
information about the patient's presenting problem and the
diagnostic and therapeutic services provided during the emergency
department visit.
◉Ambulatory Care. Answer: ____________ includes care provided in
physicians' offices, group practices, and clinics, as well as hospital
outpatient, neighborhood health, public health, industrial health,
and urgent care settings.
◉problem list. Answer: Ambulatory care records contains a
__________ which functions to facilitate ongoing patient care
management. This describes any significant current and past
illnesses and conditions as well as the procedures the patient has
undergone.
◉ambulatory surgery. Answer: Medicare requires that _________
include the following: Registration forms, documentation of the
, patient's informed consent to surgical treatment, significant medical
history and physical examination, preoperative studies, operative
report, pathology report for tissue removed, allergies and abnormal
drug reactions, record of anesthesia administration, recovery room
record, and discharge diagnosis.
◉federal
state. Answer: The regulations that govern long-term care facilities
vary. Most SNFs and NFs are governed by both _______ and _______,
including Medicare Conditions of Participation.
◉Source-oriented. Answer: ___________ records are grouped together
according to their point of origin.
◉Problem-oriented. Answer: A ____________ health record contains a
problem list as well as a patient database, an initial care plan, and
progress notes.
◉Subjective, Objective, Assessment, and Plan. Answer: A SOAP
format for a progress note includes:
◉Subjective. Answer: ___________ relates significant information in the
patient's words or from the patient's point of view.
EXAM STUDY GUIDE 2026 COMPLETE
QUESTIONS AND SOLUTIONS
◉Emergency Care. Answer: _____________ documentation includes
information about the patient's presenting problem and the
diagnostic and therapeutic services provided during the emergency
department visit.
◉Ambulatory Care. Answer: ____________ includes care provided in
physicians' offices, group practices, and clinics, as well as hospital
outpatient, neighborhood health, public health, industrial health,
and urgent care settings.
◉problem list. Answer: Ambulatory care records contains a
__________ which functions to facilitate ongoing patient care
management. This describes any significant current and past
illnesses and conditions as well as the procedures the patient has
undergone.
◉ambulatory surgery. Answer: Medicare requires that _________
include the following: Registration forms, documentation of the
, patient's informed consent to surgical treatment, significant medical
history and physical examination, preoperative studies, operative
report, pathology report for tissue removed, allergies and abnormal
drug reactions, record of anesthesia administration, recovery room
record, and discharge diagnosis.
◉federal
state. Answer: The regulations that govern long-term care facilities
vary. Most SNFs and NFs are governed by both _______ and _______,
including Medicare Conditions of Participation.
◉Source-oriented. Answer: ___________ records are grouped together
according to their point of origin.
◉Problem-oriented. Answer: A ____________ health record contains a
problem list as well as a patient database, an initial care plan, and
progress notes.
◉Subjective, Objective, Assessment, and Plan. Answer: A SOAP
format for a progress note includes:
◉Subjective. Answer: ___________ relates significant information in the
patient's words or from the patient's point of view.
