HIM 410: MODULE 1: HEALTH DATA CONTENT AND
STANDARDS| ACTUAL QUESTIONS & CORRECT ANSWER
LATEST 2025!
1. Which of the following is a form or view that is typically seen in the health
record of a long-term care patient but is rarely seen in records of acute care
patients?
emergency record
medical consultation
pharmacy consultation
physical exam ANS >> Pharmacy Consultation
Pharmacy consults are required for elderly patients who typically take multiple med-
ications. These consults review for potential drug interactions and/or discrepancies
in medications given and those ordered.
2. The health care providers at your hospital do a very thorough job of periodic
open record review to ensure the completeness of record documentation.
A qualitative review of surgical records would likely include checking for
documentation regarding
a) whether the severity of illness and/or intensity of service warranted acute
level care.
b) the presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed.
c) whether a postoperative infection occurred and how it was treated.
d) the quality of follow-up care. ANS >> B) the presence or absence of such
items as preoperative and postoperative diagnosis, description of findings, and
https://www.stuvia.com/user/Mboffin
, specimens removed.
"Whether a postoperative infection occurred and how it was treated" represents
an appropriate job for the infection control officer. "The quality of follow-up care"
represents the clinical care evaluation process, rather than the review of quality
documentation. "Whether the severity of illness and/or intensity of service warranted
acute level care" is a function of the utilization review program. The correct answer
is "the presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed."
3. For inpatients, the first data item collected of a clinical nature is usually
review of systems.
https://www.stuvia.com/user/Mboffin
, expected payer.
admitting diagnosis.
principal diagnosis. ANS >> admitting diagnosis.
Clinical data include all health care information collected during a patient's episode
of care. During the registration or intake process, the admitting diagnosis, provided
by the attending physician, is entered on the face sheet. If the patient is admitted
through the ED, the chief complaint listed on the ED record is usually the first clinical
data collected. The principal diagnosis is often not known until after diagnostic tests
are conducted. Demographic data are not clinical in nature. The review of systems
is collected during the history and physical, which is typically done after admission
to the hospital.
4. You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
physicians' index.
number control index.
patient index.
disease index. ANS >> disease index.
The major sources of case findings for cancer registry programs are the pathology
department, the disease index, and the logs of patients treated in radiology and other
outpatient departments. The number index identifies new health record numbers and
the patients to whom they were assigned. The physicians' index identifies all patients
treated by each doctor. The patient index links each patient treated in a facility with
the health number under which the clinical information can be located.
5. Joint Commission does not approve auto authentication of entries in a
health record. The primary objection to this practice is that
electronic signatures are not acceptable in every state.
tampering too often occurs with this method of authentication.
https://www.stuvia.com/user/Mboffin
, evidence cannot be provided that the physician actually reviewed and ap-
proved each report.
it is too easy to delegate use of computer passwords. ANS >> evidence cannot
be provided that the physician actually reviewed and approved each report.
https://www.stuvia.com/user/Mboffin
STANDARDS| ACTUAL QUESTIONS & CORRECT ANSWER
LATEST 2025!
1. Which of the following is a form or view that is typically seen in the health
record of a long-term care patient but is rarely seen in records of acute care
patients?
emergency record
medical consultation
pharmacy consultation
physical exam ANS >> Pharmacy Consultation
Pharmacy consults are required for elderly patients who typically take multiple med-
ications. These consults review for potential drug interactions and/or discrepancies
in medications given and those ordered.
2. The health care providers at your hospital do a very thorough job of periodic
open record review to ensure the completeness of record documentation.
A qualitative review of surgical records would likely include checking for
documentation regarding
a) whether the severity of illness and/or intensity of service warranted acute
level care.
b) the presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed.
c) whether a postoperative infection occurred and how it was treated.
d) the quality of follow-up care. ANS >> B) the presence or absence of such
items as preoperative and postoperative diagnosis, description of findings, and
https://www.stuvia.com/user/Mboffin
, specimens removed.
"Whether a postoperative infection occurred and how it was treated" represents
an appropriate job for the infection control officer. "The quality of follow-up care"
represents the clinical care evaluation process, rather than the review of quality
documentation. "Whether the severity of illness and/or intensity of service warranted
acute level care" is a function of the utilization review program. The correct answer
is "the presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed."
3. For inpatients, the first data item collected of a clinical nature is usually
review of systems.
https://www.stuvia.com/user/Mboffin
, expected payer.
admitting diagnosis.
principal diagnosis. ANS >> admitting diagnosis.
Clinical data include all health care information collected during a patient's episode
of care. During the registration or intake process, the admitting diagnosis, provided
by the attending physician, is entered on the face sheet. If the patient is admitted
through the ED, the chief complaint listed on the ED record is usually the first clinical
data collected. The principal diagnosis is often not known until after diagnostic tests
are conducted. Demographic data are not clinical in nature. The review of systems
is collected during the history and physical, which is typically done after admission
to the hospital.
4. You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
physicians' index.
number control index.
patient index.
disease index. ANS >> disease index.
The major sources of case findings for cancer registry programs are the pathology
department, the disease index, and the logs of patients treated in radiology and other
outpatient departments. The number index identifies new health record numbers and
the patients to whom they were assigned. The physicians' index identifies all patients
treated by each doctor. The patient index links each patient treated in a facility with
the health number under which the clinical information can be located.
5. Joint Commission does not approve auto authentication of entries in a
health record. The primary objection to this practice is that
electronic signatures are not acceptable in every state.
tampering too often occurs with this method of authentication.
https://www.stuvia.com/user/Mboffin
, evidence cannot be provided that the physician actually reviewed and ap-
proved each report.
it is too easy to delegate use of computer passwords. ANS >> evidence cannot
be provided that the physician actually reviewed and approved each report.
https://www.stuvia.com/user/Mboffin
