CHIMA NCE DATA & EHR QUESTIONS
AND 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 - Correct Answers -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 - Correct Answers -d
The legal health record can only be comprised of documentation that physically exists in
an electronic system.
True/False - Correct Answers –False
Mary Smith has been a patient in a variety of healthcare facilities over a period of many
years. A health record that links data from all of these care settings so it is accessible to
her current physician is called a _____ record.
a. lifelong
b. horizontal
c. developmental
d. longitudinal - Correct Answers -d
The key to an effective retention and retrieval system of health records in a facility is
_____.
a. master patient indexing
b. terminal digit filing
c. microfilming
d. optical imaging - Correct Answers -a
An EHR is defined by the fact that there is collection of data from multiple
sources, that provides decision support, and:
a. Affords a paperless environment
, b. Is used at the point of care
c. Provides for continuity of care
d. Shares data with patients - Correct Answers -c
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 - Correct Answers -b
Which of the following processes includes deficiency analysis and chart completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - Correct Answers -d
Malpractice cases generally fall into the category of _____.
a. Negligence torts
b. Intentional torts
c. Fraud cases
d. Criminal cases - Correct Answers -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 - Correct Answers -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
d. Malpractice - Correct Answers -c
A physician who performs a surgical procedure without patient consent may be
prosecuted for _____.
a. Assault
b. Battery
c. Negligence
d. Malfeasance - Correct Answers -b
Defaming another person in writing is called _____.
a. Libel
AND 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 - Correct Answers -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 - Correct Answers -d
The legal health record can only be comprised of documentation that physically exists in
an electronic system.
True/False - Correct Answers –False
Mary Smith has been a patient in a variety of healthcare facilities over a period of many
years. A health record that links data from all of these care settings so it is accessible to
her current physician is called a _____ record.
a. lifelong
b. horizontal
c. developmental
d. longitudinal - Correct Answers -d
The key to an effective retention and retrieval system of health records in a facility is
_____.
a. master patient indexing
b. terminal digit filing
c. microfilming
d. optical imaging - Correct Answers -a
An EHR is defined by the fact that there is collection of data from multiple
sources, that provides decision support, and:
a. Affords a paperless environment
, b. Is used at the point of care
c. Provides for continuity of care
d. Shares data with patients - Correct Answers -c
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 - Correct Answers -b
Which of the following processes includes deficiency analysis and chart completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - Correct Answers -d
Malpractice cases generally fall into the category of _____.
a. Negligence torts
b. Intentional torts
c. Fraud cases
d. Criminal cases - Correct Answers -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 - Correct Answers -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
d. Malpractice - Correct Answers -c
A physician who performs a surgical procedure without patient consent may be
prosecuted for _____.
a. Assault
b. Battery
c. Negligence
d. Malfeasance - Correct Answers -b
Defaming another person in writing is called _____.
a. Libel
